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Dispensary  Department  Bulletin  No.  1 


NURSES'  PAPERS 


ON 


TUBERCULOSIS 


PUBLISHED  BY  THE 

CITY  OF  CHICAGO 
MUNICIPAL  TUBERCULOSIS  SANITARIUM/ 

SEPTEMBER  1914 


CITY  OF  CHICAGO 
MUNICIPAL  TUBERCULOSIS  SANITARIUM 


STAFF  OF  NURSES 

-  OF   THE  - 

DISPENSARY  DEPARTMENT 


ROSALIND  MACKAY,  R.  N.,  Superintendent  of  Nurses 


ANNA  G.  BARRETT 
BARBARA  H.  BARTLETT 
OLIVE  E,  SEASON 
ELLA  M.  BLAND 
KATHRYN  M.  CANFIELD 
MABEL  F.  CLEVELAND 
ELRENE  M.  COOMBS 
MARGARET  M.  COUGHLIN 
STELLA  W.  COULDREY 
EMMA  W.  CRAWFORD 
FANNIE  J.  DAVENPORT 
ROXIE  A.  DENTZ 
C.  ETHEL  DICKINSON 
ANNA  M.  DRAKE 
MARY  E.  EGBERT 


MAUDE  F.  ESb._ 

SARA  D.  FAROLL 

MARY  FRASER 

AUGUSTA  A.  GOUGH 

FRANCES  M.  HEINRICH 

LAURA  K.  HILL 

ISABELLA  J.  JENSEN 

EMMA  E.  JONES 

LETTA  D.  JONES 

JEANETTE  KIPP 

ELSA  LUND 

MARY  MACCONACHIE 

JOSEPHINE  V.  MARK 

ISABEL  C.  MCKAY 

ANNA  V.  MCVADY 

ANNIE  MORRISON 

KARLA  STRIBRNA,  Interpreter. 


KATHERINE  M.  PATTERSOI 
LAURA  A.  REDMOND 
GRACE  M.  SAVILLE 
BERYL  SCOTT 
FLORENCE  T.  SINGLETON 
MABELLE  SMITH 
FLORENCE  A.  SPENCER 
HARRIETT  STAHLEY 
GENEVIEVE  E.  STRATTON 
ANNABEL  B.  STUBBS 
ALICE  J.  TAPPING 
OLIVE  TUCKER 
ELIZABETH  M.  WATTS 
MARY  C.  WRIGHT 
MARY  C.  YOUNG 


BOARD  OF  DIRECTORS 

THEODORE  B.  SACHS,  M.  D.,       -       President 


GEORGE  B.  YOUNG,  M.  D., 

W.   A.  WlEBOLDT. 


-    Secretary 


GENERAL  OFFICE 

1O5  West  Monroe  Street 

FRANK  E.  WING,  Executive  Officer. 


Dispensary  Department  Bulletin  No.  1 


NURSES'  PAPERS 


ON 


TUBERCULOSIS 

READ  BEFORE  THE 

NURSES'  STUDY  CIRCLE 

OF  THE 

DISPENSARY  DEPARTMENT 
CHICAGO  MUNICIPAL  TUBERCULOSIS  SANITARIUM 


PUBLISHED  BY  THE 

CITY  OF  CHICAGO 

MUNICIPAL  TUBERCULOSIS  SANITARIUM 

105  WEST  MONROE  STREET 

SEPTEMBER  1914 


CONTENTS 


PAGE 

Introduction — Nurses'  Tuberculosis  Study  Circle 5 

Historical  Notes  on  Tuberculosis 7 

ROSALIND  MACKAY,  R.  N. 

Visiting  Tuberculosis  Nursing  in  Various  Cities  of  the  United 

States 11 

ANNA  M.  DRAKE,  R.  N. 

Provisions  for  Out-door  Sleeping 30 

MAY  MACCONACHIE,  R.  N. 

Some  Points  in  the  Nursing  Care  of  the  Advanced  Consumptive     .    37 

ELSA  LUND,  R.  N. 

Open  Air  Schools  in  This  Country  and  Abroad .    44 

FRANCES  M.  HEINRICH,  R.  N. 

Notes  on  Tuberculin  for  Nurses  56 


NURSES'  TUBERCULOSIS  STUDY  CIRCLE 


It  is  well  known  that  the  gathering  of  facts  and  study  of  liter- 
ature essential  to  the  preparation  of  a  paper  on  a  certain  subject 
is  a  very  productive  method  of  acquiring  information.  If  the  paper 
is  to  be  presented  to  your  own  group  of  co-workers,  and  the  subject 
covered  by  it  represents  an  important  phase  of  their  work,  or  an 
analysis  of  some  of  its  underlying  principles,  then  there  is  a  further 
incentive  to  do  your  best,  as  well  as  an  opportunity  for  a  general 
discussion  which  acts  as  a  sieve  for  the  elimination  of  false  ideas 
and  gradual  formulation  of  true  conceptions. 

Lectures  on  various  phases  of  the  work  being  done  by  a  par- 
ticular group  of  people  are  very  important.  Papers  by  the  workers 
themselves  are,  however,  greatest  incentives  to  study  and  self- 
advancement. 

With  this  view  in  mind,  I  suggested  the  organization  of  a 
Tuberculosis  Study  Circle  by  the  Dispensary  Nurses  of  the  Munici- 
pal Tuberculosis  Sanitarium.  The  nurses  chosen  to  present  papers 
on  particular  phases  of  tuberculosis  are  given  access  to  the  library 
of  the  General  Office  of  the  Sanitarium;  they  are  also  given  the 
assistance  of  the  General  Office  in  procuring  all  the  necessary  in- 
formation through  correspondence  with  various  organizations  and 
institutions  in  Chicago  and  other  cities. 

As  the  program  stands  at  present,  the  Nurses'  Study  Circle 
meets  twice  a  month.  At  one  of  these  meetings  a  lecture  on  some 
important  phase  of  tuberculosis  is  given  by  an  outside  speaker, 
and  at  the  next  meeting  a  paper  is  read  by  one  of  the  curses.  At 
all  of  these  meetings  the  presentation  of  the  subject  is  followed 
by  general  discussion.  The  program  since  January,  1914,  was  as 
follows : 

January  9th,  1914 — "Historical  Notes  on  Tuberculosis,"  by 
Miss  Rosalind  Mackay,  Head  Nurse,  Stock  Yards  Dispensary  of 
the  Municipal  Tuberculosis  Sanitarium. 


72396 


January  23rd,  1914 — "Channels  of  Infection  and  the  Pathology 
of  Tuberculosis,"  by  Professor  Ludwig  Hektoen  of  the  University 
of  Chicago. 

February  13th,  1914 — "Visiting  Tuberculosis  Nursing  in  Vari- 
ous Cities  of  the  United  States,"  by  Miss  Anna  M.  Drake,  Head 
Nurse,  Policlinic  Dispensary  of  the  Municipal  Tuberculosis  Sani- 
tarium. 

March  13th,  1914 — "Provisions  for  Outdoor  Sleeping,"  by  Miss 
May  MacConachie,  Head  Nurse,  St.  Elizabeth  Dispensary  ot  the 
Municipal  Tuberculosis  Sanitarium. 

March  27th,  1914— "What  Should  Constitute  a  Sufficient  and 
Well  Balanced  Diet  for  Tuberculous  People,"  by  Mrs.  Alice  P. 
Norton,  Dietitian  of  Cook  County  Institutions. 

April  10th,  1914 — "Some  Points  in  the  Nursing  Care  of  the 
Advanced  Consumptive,"  by  Miss  Elsa  Lund,  Head  Nurse  of  the 
Iroquois  Memorial  Dispensary  of  the  Municipal  Tuberculosis  Sani- 
tarium. 

May  15th,  1914 — "Open  Air  Schools  in  This  Country  and 
Abroad,"  by  Miss  Frances  M.  Heinrich,  Head  Nurse  of  the  Post- 
Graduate  Dispensary  of  the  Municipal  Tuberculosis  Sanitarium. 

May  29th,  1914 — "Efficient  Disinfection  of  Premises  After 
Tuberculosis,"  by  Professor  P.  G.  Heinemann,  Department  of  Bac- 
teriology, University  of  Chicago. 

The  organization  of  the  Tuberculosis  Study  Circle  among  the 
nurses  of  the  Dispensary  Department  of  the  Municipal  Tuberculosis 
Sanitarium,  calling  forth  the  best  efforts  of  the  nurses  in  getting 
information  on  various  phases  of  tuberculosis  for  presentation  to 
their  co-workers  in  an  interesting  manner  has,  no  doubt,  stimulated 
the  progress  of  our  entire  nursing  force.  The  first  five  papers  pre- 
sented by  the  nurses  are  given  in  this  series.  The  pamphlet  is 
published  with  the  idea  of  attracting  the  attention  of  other 
organizations  to  this  method  of  stimulating  more  intensive  study 
among  their  nurses. 

THEODORE  B.  SACHS,  M.  D.,  President 

Chicago  Municipal  Tuberculosis  Sanitarium. 


HISTORICAL  NOTES  ON  TUBERCULOSIS 


By  ROSALIND  MACKAY,  R.  N. 

Head  Nurse,  Stock  Yards  Dispensary  of  the  Chicago  Municipal 
Tuberculosis  Sanitarium. 


So  far  as  our  information  goes,  pulmonary  tuberculosis  has 
always  existed.  It  is,  as  Professor  Hirsch  remarks,  "A  disease  of 
all  times,  all  countries,  and  all  races.  No  climate,  no  latitude,  no 
occupation,  forms  a  safeguard  against  the  onset  of  tuberculosis, 
however  such  conditions  may  mitigate  its  ravages  or  retard  its 
progress.  Consumption  dogs  the  steps  of  man  wherever  he  may 
be  found,  and  claims  its  victims  among  every  age,  class  and  race." 

Hippocrates,  the  most  celebrated  physician  of  antiquity  (460- 
377  B.  C.),  and  the  true  father  of  scientific  medicine,  gives  a 
description  of  pulmonary  tuberculosis,  ascribing  it  to  a  suppuration 
of  the  lungs,  which  may  arise  in  various  ways,  and  declares  it  a 
disease  most  difficult  to  treat,  proving  fatal  to  the  greatest  number. 

Isocrates,  also  a  Greek  physician  and  contemporary  of  Hippo- 
crates, was  the  first  to  write  of  tuberculosis  as  a  disease  trans- 
missible through  contagion. 

Aretaeus  Cappadox  (50  A.  D.)  describes  tuberculosis  as  a 
special  pathological  process.  His  clinical  picture  is  considered  one 
of  the  best  in  literature. 

Galen  (131-201  A.  D.)  did  not  get  much  beyond  Hippocrates 
in  the  study  of  tuberculosis,  but  was  very  specific  in  his  recom- 
mendation of  a  milk  diet  and  dry  climate.  He  held  it  dangerous 
to  pass  an  entire  day  in  the  company  of  a  tuberculous  patient. 

During  the  next  fifteen  centuries,  a  period  known  as  the 
Dark  Ages  and  characterized  by  most  intense  intellectual  stagna- 
tion, little  was  added  to  the  knowledge  of  pulmonary  tuberculosis. 
In  the  seventeenth  century  Franciscus  Sylvius  brought  out  the  rela- 
tionship between  phthisis  and  nodules  in  the  lymphatic  glands. 
This  was  the  first  step  toward  accurate  knowledge  of  the 
pathology  of  tuberculosis. 

Richard  Morton,  an  English  physician,  wrote,  in  1689,  of  the 
wide  prevalence  of  pulmonary  tuberculosis,  and  recognized  the  two 
types  of  fever:  the  acute  inflamatory  at  the  beginning,  and  the 


hectic  at  the  end.  He  also  recognized  the  contagious  nature  of  the 
disease  and  recommended  fresh  air  treatment.  He  believed  the 
disease  curable  in  the  early  stages,  but  warned  us  of  its  liability 
to  recur.  Morton  taught  that  the  tubercle  was  the  pathological 
evidence  of  the  disease. 

In  1690,  Leeuwenhoek,  a  Dutch  lens  maker,  started  the  making 
of  short  range  glasses  which  resulted  later  in  the  modern  micro- 
scope, making  possible  the  establishment  of  the  germ  theory  of 
disease,  including  the  establishment  of  that  theory  for  tuberculosis. 

Starck,  whose  observations  and  writings  were  published  in 
1785  (fifteen  years  after  his  death),  gave  a  more  accurate  descrip- 
tion of  tubercles  than  had  ever  been  given  before,  and  showed  how 
cavities  were  formed  from  them. 

Leopold  Auenbrugger  introduced  into  medicine  the  method  of 
recognizing  diseases  of  the  chest  by  percussion,  tapping  directly 
upon  the  chest  with  the  tips  of  his  fingers.  The  results  of  his 
investigations  were  published  in  a  pamphlet  in  1761.  This  new 
practice  was  ignored  at  first,  but  after  the  work  of  Auenbrugger 
was  translated  he  attained  a  European  reputation  and  a  revolution 
in  the  knowledge  of  diseases  of  the  chest  followed. 

Boyle  recognized  in  miliary  tubercle,  as  it  was  afterwards 
called  by  him,  the  anatomical  basis  of  tuberculosis  as  a  general 
disease,  and,  in  1810,  published  the  results  of  one  of  the  most  com- 
plete researches  in  pathology.  He  described  the  stages  in  the  devel- 
opment of  the  disease,  using  miliary  tubercle  as  its  starting  point. 
He  opposed  the  theory  that  inflammation  caused  tuberculosis  and 
declared  hemorrhage  a  result  and  not  a  cause  of  consumption. 

Laennec  discovered  one  of  the  most  important,  perhaps,  of 
all  methods  of  medical  diagnosis — that  of  auscultation.  By  means 
of  the  stethoscope,  which  he  invented  in  1819,  he  recognized  the 
physical  signs  and  made  the  first  careful  study  of  the  healing  of 
tuberculosis ;  he  gave  also  one  of  the  best  accounts  of  the  sputum  of 
the  consumptive.  He  believed  that  every  manifestation  of  the 
disease  in  man  or  animals  was  due  to  one  and  the  same  cause. 

Up  to  this  time  the  views  which  were  held  concerning  the 
infectious  nature  of  tuberculosis  were  not  based  upon  direct  ex- 
periment, but  in  1843  Klenke  produced  artificial  tuberculosis  by 
inoculation.  He  injected  tuberculous  matter  into  the  jugular  vein 
of  a  rabbit,  and  six  months  later  found  tuberculosis  of  the  liver 
and  lungs.  He  did  not  continue,  however,  his  researches;  so  they 
were  soon  forgotten. 

To  Villemin,  a  French  physician,  belongs  the  immortal  fame  of 
being  the  first  to  show  the  essential  distinction  in  tuberculosis 

8 


between  the  virus  causing  the  disease  and  the  lesion  produced  by 
it.  By  inoculating  animals,  he  demonstrated  that  tuberculosis  is  a 
specific  disease  caused  by  a  specific  agent.  His  paper  presented  in 
1865  before  the  Academy  of  Medicine  in  France  contained  a  detailed 
account  of  his  experimental  investigations.  This  was  a  most  re- 
markable contribution  to  scientific  medicine. 

It  remained  for  Robert  Koch  in  1882,  after  years  of  pains- 
taking investigation,  to  announce  to  the  world  the  discovery  of  a 
definite  bacillus  as  the  causative  agent  in  all  forms  of  tuberculous 
lesions.  Koch  isolated,  cultivated  outside  the  body,  described  and 
differentiated  the  infective  organism  of  tuberculosis  and  proved 
that  it  could  continue  to  produce  the  same  lesions  indefinitely.  He 
showed  the  presence  of  the  bacilli  in  all  known  tuberculous  lesions 
and  in  tuberculous  expectoration,  and  demonstrated  the  virulence 
in  sputum  which  had  been  dried  for  eight  weeks. 

Following  directly  upon  the  knowledge  of  the  cause  of  tuber- 
culosis came  the  recognition  of  its  curability,  and  the  proper  means 
of  its  prevention.  Although  good  food  and  fresh  air  have  always 
been  considered  of  importance  in  the  treatment  of  the  disease, 
it  was  not  until  the  middle  of  the  nineteenth  century  that  anything 
like  systematic  treatment  was  underaken. 

Dr.  George  Bodingon  of  Button,  Coldfield,  England,  wrote  an 
essay  in  1840  advocating  fresh  air  treatment.  He  denounced  the 
common  hospital  in  large  towns  as  a  most  unfit  place  for  con- 
sumptive patients,  and  established  a  home  for  their  care,  but  met 
with  so  much  opposition  that  it  was  soon  closed. 

In  1856,  Hermann  Brehmer  wrote  a  thesis  on  the  subject  which 
has  been  the  foundation  of  our  modern  treatment.  He  opened  a 
small  sanatorium  in  1864.  Five  years  later  he  established  the 
sanatorium  at  Goerbersdorf ,  in  Silesia,  which  eventually  became  the 
largest  in  the  world.  He  advocated  life  in  the  open  air,  abundant 
dietary  and  constant  medical  supervision.  He  believed  that  the 
heart  of  the  large  majority  of  consumptives  is  small  and  unde- 
veloped, and  that  this  predisposes  them  to  the  disease.  In  accord- 
ance with  this  theory  he  put  a  great  deal  of  emphasis  on  exercise  in 
the  treatment  of  his  patients.  He  built  walks  of  various  grades  on 
the  grounds  of  his  sanatorium  and  installed  a  system  of  walking 
exercise.  Patients  began  with  the  lowest  grade,  gradually  accus- 
toming themselves  to  ascend  to  the  highest.  Brehmer  was  him- 
self a  consumptive,  and  was  cured  by  the  method  he  so  firmly 
believed  in. 

Dr.  Dettweiler,  who  opened  the  second  sanatorium  in  Germany, 
at  Falkenstein,  near  Frankfort,  was  also  a  consumptive,  having  de- 

9 


veloped  tuberculosis  during  the  arduous  campaign  in  the  Franco- 
Prussian  War  in  1871.  He  entered  the  Goerbersdorf  Sanatorium  as 
a  patient,  becoming  later  an  assistant  of  Brehmer.  Dr.  Dettweiler 
laid  great  emphasis  upon  rest  in  treatment. 

In  1888,  Dr.  Otto  Walther  opened  his  famous  sanatorium  at 
Nordrach  in  the  Black  Forest,  in  Germany. 

The  first  sanatorium  for  the  care  of  the  consumptive  in  the 
United  States  was  opened  at  Saranac  Lake  by  Dr.  Edward  L. 
Trudeau  in  1884.  He  was  the  pioneer  of  the  sanatorium  treatment 
in  this  country,  and  an  example  of  what  a  man,  although  tuberculous 
himself,  can  do  for  his  fellow  men.  In  1874,  a  seemingly  help- 
less invalid,  he  made  his  home  in  the  Adirondack  Mountains. 
A  little  more  than  twenty-five  years  ago  he  became  the  founder  of 
a  village  now  crowded  with  tuberculous  patients.  The  Saranac  Lake 
institution,  which  began  with  one  small  cottage,  has  since  developed 
into  the  best  known  sanatorium  in  this  country. 

In  1891,  Dr.  Herman  Biggs  posted  the  first  anti-spitting  ordi- 
nance in  the  street  railway  cars  of  New  York. 

Dr.  Lawrence  Flick  brought  about  the  formation  of  the  first 
anti-tuberculosis  society  in  1892,  and  in  1894  the  City  of  New  York 
adopted  a  law  to  enforce  notification  and  registration. 

Dr.  Philip  of  Edinburgh  was  the  first  to  systematically  and 
completely  organize  the  anti-tuberculosis  campaign.  In  1887  he 
inaugurated  that  new  institution,  the  anti-tuberculosis  dispensary,  which 
has  since  rendered  such  inestimable  service.  The  fundimental  principle 
of  the  Edinburgh  system  is  that  the  disease  should  be  sought  out 
in  its  haunts. 

The  first  dispensary  in  the  United  States  was  opened  in  New 
York  in  1904,  modeled  after  the  Edinburgh  system.  About  the 
same  time  came  the  Open  Air  Schools — Charlottenburg  establish- 
ing one  in  1904  and  Providence,  R.  I.,  following  in  1908.  The  first 
Day  Camp  in  the  United  States  was  opened  in  1905  in  Boston.  New 
Jersey  established  the  first  Preventorium  for  Children  at  Farm- 
ingdale  in  1909.  All  this  naturally  led  to  better  provision  for 
advanced  cases;  sanatoria  for  hopeful  cases  at  small  cost;  factory 
inspection;  and,  in  some  countries,  industrial  colonies  for  arrested 
cases. 

The  tuberculosis  patient  of  today  presents  a  hopefulness  pre- 
viously undreamt  of.  The  outlook  is  brighter  with  promise  than 
ever  before,  and  we  have  every  reason  to  look  forward  to  a  steady 
reduction  in  the  mortality  rate  from  this  dread  disease;  but  the 
extinction  of  tuberculosis  will  be  achieved  only  when  the  social  and 
economic  problems  have  been  solved. 

10 


VISITING  TUBERCULOSIS  NURSING  IN  VARIOUS 
CITIES  OF  THE  UNITED  STATES 

By  ANNA  M.  DRAKE,  R.  N. 

Head  Nurse,  Policlinic  Dispensary  of  the  Municipal  Tuberculosis 

Sanitarium. 


BALTIMORE 

In  1903,  the  first  visiting  tuberculosis  nurse  was  assigned  in 
Baltimore  to  follow  up  patients  of  the  Johns  Hopkins  Hospital 
Out-patient  Department.  Her  duties  were  varied  as  are  the 
duties  of  the  present  day  tuberculosis  nurse.  She  was  to  instruct 
patients  in  the  use  of  sunlight  and  fresh  air  and  was  allowed  to 
furnish  them  with  special  diet  in  the  shape  of  milk  and  eggs.  She 
investigated  home  conditions  and  helped  improve  sleeping  quarters. 
She  placed  patients  in  sanatoria,  or  brought  them  back  to  the  dis- 
pensary for  treatment.  She  gave  bedside  care  to  advanced  cases, 
if  she  could  not  get  them  into  hospitals,  and  applied  to  relief  orga- 
nizations for  help  in  solving  the  problems  of  the  family.  From 
time  to  time  other  nurses  of  the  Baltimore  Visiting  Nurse  Asso- 
ciation were  assigned  to  the  work,  other  dispensaries  and  agencies 
began  referring  cases  to  be  followed  up,  and  the  work  grew  to  such 
proportions  as  to  be  almost  unmanageable  for  a  private  organi- 
zation. 

In  1910,  the  Tuberculosis  Division  of  the  Balitmore  Health 
Department  was  organized.  It  began  its  activities  with  a  corps 
of  fifteen  nurses  and  a  visiting  list  of  1,617  patients  turned  over 
to  it  by  the  Baltimore  Visiting  Nurse  Association.  The  object  of 
the  Tuberculosis  Division  was  to  bring  under  the  supervision  of  the 
Health  Department  all  persons  in  the  city  suffering  with  pulmonary 
tuberculosis.  Ambulatory  cases  were  to  be  given  advice  and  in- 
struction ;  advanced  cases,  bedside  care,  if  needed,  or  hospital  care, 
if  available.  At  present,  it  is  upon  the  advanced  cases,  as  well  as 
those  who  are  in  contact  with  them,  that  the  nurses  of  the  Tuber- 
culosis Division  concentrate  their  efforts.  The  Staff  at  present  con- 
sists of  a  Superintendent  and  sixteen  Field  Nurses.  The  city  is 

11 


divided  into  sixteen  districts,  a  nurse  being  assigned  to  each  district. 
Each  nurse  is  responsible  for  the  care  of  all  cases  of  tuberculosis  in 
her  district. 

In  1912,  the  Tuberculosis  Division  opened  two  municipal  tuber- 
culosis dispensaries.  These  dispensaries  receive  patients  on  alter- 
nate days  from  3  to  5  p.  m.,  nurses  in  districts  nearest  the  dispen- 
saries alternating  for  clinic  duty.  Other  dispensaries  are  the  Phipps 
Tuberculosis  Dispensary  at  Johns  Hopkins  Hospital,  and  the  Uni- 
versity of  Maryland  Hospital  Tuberculosis  Dispensary. 

The  problems  which  chiefly  concern  the  Tuberculosis  Division 
in  its  efforts  to  control  the  spread  of  tuberculosis  in  Baltimore  are 
the  failure  of  physicians  to  report  cases  to  the  Department  of 
Health  until  the  patient  is  in  a  dying  condition,  and  the  inadequate 
provision  for  hospital  care  of  advanced  cases.  These  conditions  are 
particularly  marked  in  the  case  of  colored  patients,  who  are 
found  going  in  and  out  of  homes,  restaurants,  and  laundries,  as 
cooks,  waitresses  and  servants  of  various  kinds,  as  long  as  they  are 
able  to  drag  themselves  about. 

The  nurses  of  the  Tuberculosis  Division  are  graduate  nurses 
and  are  registered.  They  are  paid  $75  a  month,  with  car  fare 
and  telephone  expenses,  and  are  allowed  two  weeks'  vacation  with 
pay.  They  are  not  required  to  take  a  Civil  Service  examination,  but 
are  carefully  selected  with  a  view  to  obtaining  women  of  a  high 
grade  of  efficiency.  They  wear  uniforms  of  blue  denim  with  simple 
hats  and  coats,  but  not  of  uniform  design.  Each  nurse  wears  under 
the  lapel  of  her  coat  a  badge  reading  "Nurse — Baltimore  Health 
Department,"  which  she  uses  on  occasions.  The  nurses  report  to 
the  Superintendent  each  morning  at  8 :30  to  hand  in  reports  of  the 
previous  day's  work,  to  stock  their  bags,  and  to  receive  new  work 
for  the  day.  At  noon  each  nurse  reports  at  her  branch  office,  of 
which  there  are  seven,  each  situated  on  border  lines  of  adjoining 
districts.  An  hour  is  spent  at  the  branch  office  for  lunch  and  rest, 
for  receiving  telephone  calls  and  for  restocking  the  bags  for  after- 
noon rounds.  The  nurse  leaves  her  district  at  four  o'clock  to  attend 
to  about  an  hour's  clerical  work,  which  is  usually  done  at  home. 

The  average  number  of  patients  per  nurse  is  212,  about  four 
per  cent  of  whom  are  bed  cases.  These  bed  patients  are  visited 
two  or  three  times  a  week,  while  ambulatory  cases  are  visited  on  an 
average  of  twice  a  month.  During  the  year  1912  the  sixteen  nurses 
made  72,058  visits  for  instruction  and  nursing  care. 
NEW  YORK 

The  oldest  tuberculosis  clinic  in  New  York  City  is  connected 
with  the  New  York  Nose,  Throat  and  Lung  Hospital;  it  was  es- 

12 


tablished  in  1894.  In  1895,  the  Presbyterian  Hospital  estab- 
lished a  special  tuberculosis  clinic.  In  1902,  the  Vanderbilt  Clinic 
organized  a  special  class  for  the  treatment  of  tuberculosis.  In 
1903,  Gouverneur  and  Bellevue  Hospitals  and,  in  1904,  Harlem  Hos- 
pital added  Tuberculosis  Clinics.  These  were  followed  during  the 
next  few  years  by  the  establishment  of  many  others.  In  1906,  when 
the  Tuberculosis  Relief  Committee  of  the  New  York  Charity  Orga- 
nization Society  began  its  work  among  the  tuberculous  poor  of  the 
city,  it  met  at  every  turn  instances  of  overlapping  and  duplication 
in  the  work  done  by  the  various  clinics.  This  lack  of  co-operation, 
with  the  resulting  difficulties  encountered  by  the  Committee  in  its 
endeavor  to  efficiently  administer  its  special  tuberculosis  fund,  dem- 
onstrated the  advisability  of  forming  an  organization  having  as  its 
object  the  co-ordination  of  the  work  of  the  various  tuberculosis 
clinics.  In  1908,  nine  of  these  clinics  and  several  allied  philanthropic 
agencies  were  organized  into  the  Association  of  Tuberculosis  Clinics. 
Today  there  are  29  clinics,  14  philanthropic  institutions  and  organ- 
izations, five  departments  of  municipal  and  state  government,  six 
tuberculosis  institutions,  and  numerous  other  institutions  and  or- 
ganizations having  special  interest  in  tuberculosis  work.  Of  the  29 
clinics,  eleven  are  under  the  supervision  of  the  Department  of 
Health,  three  are  connected  with  city  hospitals,  and  the  remainder 
are  operated  by  private  institutions.  This  voluntary  association 
of  private  and  municipal  dispensaries,  sharing  equal  responsibilities 
and  acknowledging  equal  obligations,  is  a  striking  feature  of  tuber- 
culosis work  in  New  York  and  presents  a  unique  example  of  co- 
operation. 

The  task  of  standardizing  the  clinics  was  a  difficult  one.  One 
clinic  had  ten  rooms  with  every  convenience.  Another  had  one 
room  and  no  conveniences.  Some  clinics  made  no  provision  for 
sputum  beyond  a  cuspidor ;  others  provided  gauze  or  paper  napkins 
when  patients  entered  the  room.  Two  clinics  provided  no  drinking 
water ;  two  had  a  metal  water  cooler  in  the  waiting  room ;  one  pro- 
vided sanitary  drinking  cups ;  and  another  had  two  enamel  drinking 
cups  chained  to  the  wall.  Some  clinics  had  sanitary  fountains;  in 
others  the  nurse  kept  a  glass  on  hand  for  the  patients.  Neither 
was  there  any  uniformity  in  matters  of  dress.  Nurses  and  doctors 
at  some  clinics  wore  ordinary  street  clothes.  At  other  clinics,  gowns 
or  aprons,  with  or  without  sleeves,  were  worn.  Three  clinics  occu- 
pied separate  buildings  of  their  own.  Four  clinics  provided  separate 
waiting-rooms  for  tuberculous  patients.  At  one  dispensary  the  tu- 
berculous patients  had  the  use  of  the  general  waiting  room,  there 
being  no  other  clinics  held  at  that  time;  other  clinics  made  no  dis- 

13 


tinction,  tuberculous  patients  using  the  general  waiting  room  in 
company  with  patients  attending  other  clinics.  After  studying  the 
conditions  existing  in  the  various  clinics,  it  was  decided  that  to 
belong  to  the  association  each  clinic  must  subscribe  to  and  comply 
with  the  following  regulations: 

a.  Tuberculous  patients  must  be  segregated  in  a  separate 
class. 

b.  Home  supervision  of  all  cases  by  a  graduate  nurse  espe- 
cially assigned  for  this  purpose  must  be  maintained. 

c.  Each  dispensary  must  serve  a  certain  district,  and  all  cases 
living  outside  of  this  district  must  be  transferred  to  the 
clinic  serving  the  district  within  which  they  live. 

Early  in  the  history  of  the  Association  objection  was  made  to 
this  last  rule  by  teachers  of  medicine,  who  held  that  it  tended  to 
deprive  them  of  teaching  material;  but  they  soon  fell  in  line  with 
the  other  dispensaries  when  they  saw  the  advantage  it  afforded 
them  of  improving  their  methods  without  loss  of  teaching  material, 
and  the  further  opportunity  of  securing  home  supervision. 

From  time  to  time  it  has  been  necessary  for  the  Association 
to  adopt  certain  methods  of  procedure  in  the  administration  of  the 
various  clinics.  The  general  policy  of  the  Association  is  as  follows : 

(1)  Each  clinic  should  arrange  for  a  physician  to  visit  and 
treat  in  their  homes  patients  who  are  too  ill  to  attend 
clinic,  for  whom  hospital  care  cannot  be  provided. 

(2)  Special  children's  clinics  should  be  established  wherever 
the  size  of  the  clinic  warrants  it. 

(3)  Sputum  of  every    patient    should    be  examined  once  a 
month ;  patients  should  be  re-examined  once  a  month,  and 
the  results  entered  on  the  records. 

(4)  The  physician  should  use  the  nurse's  report  of  home  con- 
ditions as  a  basis  for  advising  patients. 

(5)  Patients  refusing  to  attend  the  proper  dispensary  shall 
be  dismissed  as  delinquent  and  reported  to  the  Healtn  De- 
partment. 

(6)  All  supervising  nurses  should  be  affiliated  with  some  local 
relief  organization  in  order  to  better  organize  the  relief 
work  of  the  clinic. 

(7)  The  home  of  every  patient  should  be  visited  at  least  once 
a  month. 

(8)  The  classification  of  the  National  Association    for   the 
Study  and  Prevention  of  Tuberculosis  should  be  followed 
for  recording  stages  of  disease  and  condition  on  discharge. 

14 


(9)  A  uniform  system  of  record  keeping  should  be  used  by 
nurses  in  order  to  facilitate  the  compiling  of  monthly  re- 
ports. 

(10)  The  staff  of  physicians  should  be  sufficient  to  allow  at 
least  fifteen  minutes  for  the  examination  of  every  new 
case,  and  at  least  six  minutes  for  every  old  case. 

(11)  There  should  be  at  least  one  nurse  for  every  100  patients 
on  the  clinic  register. 

(12)  Sputum  cups,  or  a  proper  substitute,  should  be  furnished 
to  patients  to  take  home. 

(13)  Paper  or  gauze  handkerchiefs  should  be  given  to  each 
patient  on  entrance  to  the  clinic. 

(14)  No  cuspidors  should  be  used. 

(15)  Sanitary  fountains  or  sanitary  drinking  cups  should  be 
provided. 

(16)  Gowns    with    sleeves    should   be    worn    by   physicians. 
Nurses  should  wear  gowns  with  sleeves  or  washable  uni- 
forms while  on  duty  in  the  dispensary. 

That  the  Association  found  it  necessary  to  make  so  many  rec- 
ommendations for  the  administration  of  the  various  clinics  is  evi- 
dence of  the  diverse  systems,  and  in  some  instances,  the  entire  lack 
of  system,  in  vogue  in  some  dispensaries.  The  salary  of  nurses  in 
privately  operated  tuberculosis  dispensaries  averages  about  $75  per 
month ;  no  standard  uniform  is  in  use. 

The  first  tuberculosis  visiting  nurse  of  the  New  York  Depart- 
ment of  Health  was  appointed  March  1st,  1903.  By  January,  1910, 
the  staff  had  grown  to  158,  the  Health  Department  becoming  prac- 
tically responsible  for  the  home  supervision  of  every  registered  case 
of  tuberculosis  in  New  York  not  under  the  care  of  a  private  phy- 
sician or  in  an  institution. 

The  organization  of  the  work  of  the  new  Health  Department 
tuberculosis  nurses  has  been  based  upon  the  district  system  in  force 
among  the  Associated  Clinics.  In  each  clinic  district  a  staff  of 
Health  Department  nurses  is  maintained,  charged  with  the  sanitary 
supervision  of  cases  of  pulmonary  tuberculosis  in  that  district.  They 
visit  at  least  once  a  month  all  "at  home"  cases;  that  is,  cases  not 
regularly  attending  clinics,  not  in  an  institution,  or  not  under  a  pri- 
vate physician's  care.  These  nurses  report  daily  at  the  tuberculosis 
clinic,  which  is  used  as  a  district  headquarters,  and  there  receive 
assignments.  One  nurse  is  detailed  as  Captain,  or  supervising  nurse 
of  the  district,  and  acts  as  official  intermediary  between  the  clinic 
and  the  Department  of  Health.  Each  morning  the  nurse  tele- 
phones to  the  Department  of  Health  the  daily  report  of  her  staff  and 

15 


of  the  clinic,  and  obtains  information  received  at  the  Department 
regarding  cases  in  the  district.  In  case  of  death  or  removal  of 
tuberculous  patients  from  a  home  the  district  nurses  order  dis- 
infection of  the  premises  and  bedding ;  they  make  arrangements  for 
admission  of  patients  to  hospitals  or  sanatoria,  investigate  com- 
plaints made  by  citizens,  see  that  regulations  of  the  Department  of 
Health  regarding  expectoration  are  observed,  and  use  their  author- 
ity to  induce  delinquent  cases  to  resume  attendance  at  the  proper 
clinic.  They  also  visit  families  of  patients  in  hospitals  at  intervals.  Each 
nurse  keeps  a  complete  index  of  all  cases  of  pulmonary  tuberculosis 
in  her  district,  which  is  at  all  times  accessible  to  nurses  and  phy- 
sicians at  the  clinic. 

In  the  Department  of  Health  clinics,  the  plan  is  as  follows: 
a  supervising  nurse  who  does  no  district  work,  and  several  field 
nurses,  each  assigned  to  special  duties  on  clinic  days,  such  as  regis- 
tration room,  throat  room,  examining  rooms,  etc.  Field  nurses  are 
also  responsible  for  the  care  of  patients  in  their  sub-districts,  each 
nurse  carrying  an  average  of  about  125  patients  on  her  visiting 
list  at  one  time. 

BOSTON 

A  staff  of  twenty-five  nurses,  working  from  the  Out-patient 
Department  of  the  Boston  Consumptives'  Hospital,  has  the  super- 
vision of  all  tuberculosis  cases  in  their  homes,  and  the  follow-up 
work  on  all  discharged  sanatorium  and  hospital  cases  in  the  city  of 
Boston. 

All  cases  of  tuberculosis  reported  to  the  Health  Department, 
whether  under  the  care  of  a  private  physician  or  not,  are  visited 
at  least  once  by  a  nurse  from  this  staff,  to  see  that  they  are  carry- 
ing out  a  proper  plan  of  isolation. 

The  Boston  Consumptives'  Hospital  Dispensary,  centrally 
located,  is  open  every  morning  and  one  or  two  evenings  a  week. 
Three  or  four  nurses  are  on  duty  in  the  clinic  each  morning,  taking 
histories,  attending  nose  and  throat  room  and  preparing  patients  for 
examination.  At  the  dispensary  only  a  medical  history  of  new 
patients  is  taken,  the  social  history  being  obtained  by  the  nurse  on 
her  first  visit  to  the  home.  Pulse,  temperature  and  weight  are  also 
taken  at  the  dispensary,  after  which  the  patient  waits  his  turn  for 
examination.  Each  new  patient  is  given  an  examination  in  the  nose 
and  throat  room ;  old  patients  also,  if  necessary.  After  examination 
or  treatment,  all  patients  return  to  the  general  waiting  room.  From 
here  each  patient  is  called  before  the  Chief  of  Clinic,  who  notes  the 
general  progress  of  the  patient,  the  results  of  the  last  examination 

16 


or  any  remarks  recorded  by  the  physician,  and  the  report  of  home 
conditions  as  reported  by  the  nurse.  The  Chief  of  Clinic  advises 
the  patient  in  accordance  with  the  needs  indicated.  He  makes  no 
examinations,  but  sees  each  patient  every  time  he  comes  to  the 
clinic  and  is  thus  able  to  follow  very  carefully  the  progress  of 
each  patient  and  to  advise  such  changes  in  treatment  as  may  seem 
necessary. 

The  city  is  divided  into  twenty-two  districts,  each  nurse  being 
responsible  for  the  care  of  all  tuberculous  patients  in  her  district. 
The  number  of  patients  cared  for  by  each  nurse  is  from  100  to  180. 
A  very  small  percentage  of  bedside  care  is  given;  far  advanced 
patients  as  a  rule  are  sent  to  hospitals. 

Boston  tuberculosis  nurses  do  not  wear  uniforms.  They  are 
paid$900  a  year,  with  no  increase  for  length  of  service  or  efficiency. 

BUFFALO 

The  purpose  of  the  Buffalo  Association  for  the  Relief  and  Con- 
trol of  Tuberculosis  has  been  to  stimulate  progress  in  fighting  tuber- 
culosis. It  very  modestly  shares  with  the  city  officials  and  with 
private  charities  the  credit  for  the  work  accomplished.  All  it 
claims  for  itself  is  that  it  has  been  able,  and  will  continue,  to  "point 
the  way."  How  thoroughly  it  has  succeeded  in  this  may  be  seen  by 
the  progress  made  since  1909  when  the  Buffalo  Association  made  its 
first  appeal  for  funds.  At  that  time  Buffalo  had: 

(1)  A  dispensary  maintained  by  the  Buffalo  Charity  Organi- 
zation Society. 

(2)  The  Erie  County  Hospital  for  advanced  cases. 

(3)  A  day  camp,  with  a  capacity  of  thirty  patients,  supported 
by  a  group  of  women. 

(4)  One  visiting  nurse  supplied  by  the  District  Nursing  As- 
sociation. 

The  present  facilities  are : 

(1)  A  dispensary,  open  every  day  and  one  evening  a  week, 
with  a  nose  and  throat  clinic,  and  a  dental  clinic  with  a 
paid  dentist  in  attendance. 

(2)  The  J.  N.  Adam  Memorial  Hospital  for  early  cases,  ca- 
pacity 125,  supported  by  the  city. 

(3)  The  Municipal  Hospital  for  the  care  of  advanced  cases, 
supported  by  the  city. 

(4)  The  Erie  County  Hospital,  as  before. 

(5)  Tuberculosis    Division    of    the    Department    of    Health 
with  two  tuberculosis  inspectors  and  six  visiting  tuber- 
culosis nurses. 

17 


(6)  An  Open  Air  Camp,  with  a  capacity  of  from  seventy  to 
one  hundred  patients,  with  a   special    department    for 
children.     Patients  are  kept  day  and  night.     The  c&mp 
has  three  resident  trained  nurses  and  one  interne,  and  is 
visited  daily  by  the  Association's  paid  medical  director. 

(7)  Two  open  air  schools,  with  another  promised. 

(8)  A  City  Hospital  Commission,  with  a  plan  for  the  erection 
of  a  pavilion  for  500  advanced  cases  as  the  first  of  a  gen- 
eral hospital  scheme. 

(9)  Teachers  soon  to  be  appointed  for  the  education  of  tu- 
berculous children. 

(10)  The  trades  unions  organized  to  promote  the  campaign 
among  their  own  members  in  a  unique  organization. 

(11)  The  whole  community  alert  to  the  menace  of  tuberculosis, 
willing  to  shoulder  the  community  burden  and  to  assume 
the  community  responsibility. 

The  Dispensary  is  now  operated  by  the  Association  for  the 
Relief  and  Control  of  Tuberculosis,  and  the  nurses  are  supplied  by 
the  Health  Department.  The  nursing  staff  consists  of  a  supervising 
nurse  and  six  field  nurses,  the  latter  receiving  $720  per  year.  They 
wear  no  uniform.  They  give  a  limited  amount  of  bedside  care, 
some  member  of  the  family  being  taught  to  properly  care  for  the 
patient,  if  he  cannot  be  sent  to  a  hospital.  Recently  an  additional 
nurse  was  engaged  by  the  Association  to  follow  up  cases  on  whom 
no  diagnosis  has  been  made  and  who  have  not  returned  to  the  dis- 
pensary for  re-examination.  Since  the  Dispensary  was  opened  in 
1909,  there  have  been  over  one  thousand  such  cases.  Many  of 
these  had  suspicious  signs  when  examined,  but  there  has  hitherto 
been  no  means  of  keeping  in  touch  with  them,  as  the  nurses  have 
been  obliged  to  confine  their  attention  to  positive  cases.  One 
of  the  chief  difficulties  of  the  Buffalo  campaign,  as  elsewhere, 
has  been  the  fact  that  more  than  half  of  the  cases  have 
probably  already  infected  others.  This  latest  movement  of  the  As- 
sociation should  anticipate  this  condition  to  a  certain  extent,  and  is 
one  more  means  by  which  it  is  "blazing  the  trail"  toward  its  goal, — 
"No  uncared  for  tuberculosis  in  Buffalo  in  1915." 

PHILADELPHIA  AND  PENNSYLVANIA 

In  the  General  Appropriations  Act  of  1907  the  Legislature  of 
Pennsylvania  granted  to  the  State  Department  of  Health,  in  addi- 
tion to  its  regular  budget,  the  sum  of  $400,000,  "to  establish  and 
maintain,  in  such  places  in  the  State  as  may  be  deemed  necessary, 
dispensaries  for  the  free  treatment  of  indigent  persons  affected 

18 


with  tuberculosis,  for  the  study  of  social  and  occupational  condi- 
tions that  predispose  to  its  development,  and  for  continuing  re- 
search experiments  for  the  establishment  of  possible  immunity  and 
cure  of  said  disease." 

Immediately  after  securing  the  above  appropriation,  the  State 
Department  of  Health  began  to  establish  dispensaries  throughout 
the  state,  one  or  more  in  each  county.  The  staff  of  each  dispensary 
consists  of  a  chief,  who  is  also  county  medical  inspector,  and  a 
corps  of  assistant  physicians  and  visiting  nurses.  There  is  a  super- 
vising nurse  with  one  assistant  at  Harrisburg,  who  oversee  and 
inspect  the  work  of  the  staff  nurses. 

The  number  of  nurses  in  the  dispensaries  throughout  the  state 
varies  from  a  nurse  shared  by  another  organization  or  a  practical 
nurse  giving  part  time,  to  from  four  to  seven  nurses  in  one  dispen- 
sary. There  are  now  more  than  115  State  Department  Tuberculosis 
Dispensaries  in  Pennsylvania,  Philadelphia  having  three. 

An  idea  of  the  general  plan  of  the  work  may  be  gained  from 
a  description  given  of  the  State  Department  Dispensary  No.  21 
located  in  Philadelphia,  by  Dr.  Francine: 

"There  are  at  present  five  nurses  employed  at  Dispensary  No.  21,  two  of 
whom  give  their  whole  time  to  following  up  the  return  cases  from  the  State  Sana- 
toria. As  soon  as  the  case  is  discharged  from  the  sanatorium,  that  information, 
with  other  data  regarding  the  condition  on  discharge,  etc.,  is  sent  to  us  at  once. 
At  the  end  of  a  stated  period,  if  that  case  has  not  been  returned,  the  nurse  looks 
it  up,  and  gets  it  to  come  in.  The  nurses  make  out  detailed  reports  on  all  cases 
discharged  from  the  sanatoria,  at  periods  of  six  months,  whether  our  own  patients 
or  not.  These  will  be  and  are  valuable  for  statistical  data.  Practically  all  the  data 
for  reports  as  to  subsequent  results  in  cases  discharged  from  the  sanatoria,  which 
have  appeared  in  this  country  at  least,  have  been  made  up  from  information 
gleaned  by  writing  the  discharged  patient  and  having  him  fill  out  his  own  report. 
It  does  not  tax  the  imagination  unduly  to  conclude  which  is  the  more  accurate,  the 
answers  to  questioning  by  a  trained  worker  (we  have  selected  for  this  work  the 
two  nurses  who  have  been  with  us  longest)  who  in  addition  takes  the  tempera- 
ture, pulse,  etc.,  herself,  and  usually  succeeds  in  getting  the  patient  back  to  the 
dispensary  for  at  least  one  re-examination  ;  or  such  answers  as  a  patient  may  see 
fit  to  make  to  a  printed  questionaire. 

For  the  purpose  of  regular  dispensary  and  inspection  work,  the  dispensary 
limits  itself  to  receiving  patients  from  certain  disiricts  of  the  city,  though  as  a  state 
institution  it  is  impossible  for  the  dispensary  to  refuse  any  case,  no  matter  where 
they  live,  if  they  insist  upon  treatment.  Usually  by  a  little  persuasion,  however, 
we  can  get  the  patients  to  go  to  the  dispensary  in  their  district,  co-operating  in 
this  way  with  the  Phipps  Institute  of  the  University  of  Pennsylvania,  the  Gray's 
Ferry  State  Dispensary,  the  Kensington  Tuberculosis  Dispensary  and  the  Frank- 
ford  State  Dispensary.  The  section  of  the  city  from  which  we  draw  our  cases  is 
divided,  for  purposes  of  inspection  and  Social  Service  Work,  into  three  districts 
with  a  nurse  assigned  to  each,  and  this  gives  each  of  our  nurses,  roughly 
speaking,  about  seventy-five  patients  per  month  to  take  care  of.  These  patients 

19 


must  be  visited  regularly  every  two  weeks,  which  gives  the  nurse  at  least  one 
hundred  and  fifty  visits  a  month  to  pay,  not  including  the  visits  to  new  cases. 

Every  new  case  which  is  admitted  to  the  dispensary  must  be  visited  within 
one  week  of  the  day  of  admission.  The  nurses  come  in  from  their  visiting  work 
and  report  daily  at  12:30  o'clock,  for  one  hour  in  the  dispensary  office,  and  new 
cases,  according  to  the  district  in  which  they  live,  are  assigned  to  the  nurse  hav- 
ing charge  of  that  district.  The  advantage  of  having  a  nurse  report  daily  to  the 
dispensary  at  a  time  when  all  the  doctors  are  there,  lies  in  the  fact  that  the  doctor 
has  thus  the  opportunity  of  talking  over  with  the  nurse  the  new  cases  which  she 
is  to  visit  and  of  making  any  suggestions  which  he  has  gleaned  from  the  history 
and  examination  of  the  patient.  It  is  thus  possible  for  the  nurses  to  visit  the  new 
cases  in  the  afternoon  of  the  same  day,  The  advantage  of  this  close  co-operation 
between  doctor  and  nurse  must  be  at  once  apparent.  Further,  each  nurse  is  re- 
quired to  report  to  every  physician  one  morning  a  month,  with  the  histories  in 
hand  of  all  the  patients  of  that  particular  doctor  which  are  on  her  list.  This  is 
valuable,  because  in  no  other  way  can  the  doctor  get  so  thorough  an  understand- 
ing of  the  home  conditions  and  social  problems  of  a  given  patient  as  by  talking  the 
situation  over  directly  and  personally  with  the  nurse  in  charge." 

A  similar  plan  is  in  operation  at  the  other  two  State  Depart- 
ment Clinics  in  Philadelphia. 

The  best  known  tuberculosis  dispensary  in  Philadelphia,  con- 
ducted by  a  private  organization,  is  the  dispensary  connected  with 
the  Henry  Phipps  Institute.  This  dispensary  during  the  eleven 
years  of  its  existence  has  contributed  greatly  to  the  standardization 
of  tuberculosis  dispensary  work,  not  only  in  Philadelphia,  but 
throughout  the  entire  country.  Connected  with  a  scientifically  con- 
ducted hospital  for  advanced  cases,  with  its  laboratories  and  other 
improved  medical  facilities,  the  Dispensary  of  the  Henry  Phipps 
Institute  occupies  a  high  place  among  the  similar  institutions  of 
this  country.  The  nursing  staff  of  the  Henry  Phipps  Dispensary 
consists  of  three  visiting  tuberculosis  nurses,  aided  by  two  additional 
nurses  (both  colored)  assigned  by  other  organizations  to  work  on 
the  Phipp  Dispensary  staff,  one  by  the  Whittier  Centre,  and  the 
other  by  the  Pennsylvania  Society  for  the  Prevention  of  Tuber- 
culosis. Some  of  the  important  features  of  the  work  of  this  dis- 
pensary in  its  relation  to  nurses  are  as  follows: 

(1)  An  efficient  training  school  for  tuberculosis  nurses,  af- 
fording the  opportunity  of  hospital  and  dispensary  train- 
ing. 

(2)  A  course  of  lectures  on  tuberculosis  given  to  the  nursing 
profession  at  large. 

(3)  Intensive  home  work  among  tuberculous  families. 

Visiting  tuberculosis  work  in  Philadelphia  is  also  done  in  con- 
nection with  the  Presbyterian  Hospital  Tuberculosis  Clinic,  St. 
Stevens  Church  Tuberculosis  Clinic,  and  by  the  Visiting  Nurse  So- 
ciety of  Philadelphia. 

20 


PITTSBURGH 

The  Tuberculosis  League  Hospital  of  Pittsburgh  was  opened 
in  1907  for  incipient  and  advanced  cases,  with  a  capacity  of  eighty 
beds.  The  League  conducts  at  present  a  night  camp,  an  open  air 
school,  a  farm  colony,  a  post-graduate  course  for  nurses  and  tuber- 
culosis clinics  for  medical  students  at  its  dispensary.  There  is  also 
a  post-graduate  course  in  tuberculosis  for  nurses.  The  course  re- 
quires eight  months  and  nurses  receive  during  that  time  $25  a 
month.  Only  registered  nurses  are  accepted.  The  training  is 
along  the  following  lines:  nursing  advanced  cases  in  hospital, 
open  air  school  work,  sanatorium  care  of  early  cases,  service  in 
dental,  nose  and  throat  clinics,  and  in  the  dispensary  for  ambulant 
cases,  district  nursing,  service  in  baby  clinics,  educational  work,  and 
laboratory  work.  Patients  discharged  from  the  hospital,  families 
of  patients  in  the  hospital,  and  cases  reporting  at  various  tuber- 
culosis dispensaries,  are  given  complete  follow-up  care  by  the  nurses 
taking  the  course,  thus  giving  them  excellent  training  in  public 
health  work,  especially  that  phase  of  public  health  nursing  dealing 
with  tuberculosis.  At  present  there  are  nine  nurses  taking  the 
course.  The  Dispensary  of  the  Tuberculosis  League  employs  six 
nurses. 

Pittsburgh  has  also  a  State  Department  of  Health  Tubercu- 
losis Clinic,  with  ten  nurses,  each  caring  for  from  90  to  100  pa- 
tients per  month.  These  nurses  give  a  small  percentage'  of  bedside 
care  and  are  not  in  uniform,  except  when  on  duty  in  the  dispensary. 
They  are  paid  $70  per  month.  The  plan  of  work  is  similar  to  that 
of  the  Philadelphia  State  Dispensary. 

The  Department  of  Public  Health  of  Pittsburgh  employs  four 
visiting  nurses,  who  investigate  home  conditions  and  instruct 
patients  reported  to  the  department  who  are  not  under  the  close 
supervision  of  a  private  physician,  the  State  Department  Clinic,  or 
the  Tuberculosis  League  Clinic.  The  nurses  are  able  to  correlate, 
in  a  way,  the  work  of  the  two  dispensaries  by  assigning  patients 
to  the  clinic  in  the  district  in  which  they  live.  They  receive  $75 
per  month  and  are  not  in  uniform. 

Pittsburgh,  then,  has  in  all  twenty  visiting  tuberculosis  nurses, 
under  three  separate  and  distinct  organizations. 

CLEVELAND 

In  Cleveland,  as  in  nearly  every  other  city,  the  work  of  organiz- 
ing the  fight  against  tuberculosis  was  accomplished  by  private 
organizations,  the  Anti-Tuberculosis  League  and  the  Visiting  Nurse 
Association.  For  a  number  of  years  the  Health  Department  con- 

21 


fined  itself  to  keeping  a  card  catalogue  of  reported  cases.  In  1910 
sufficient  funds  were  voted  by  the  City  Council  to  enable  the  estab- 
lishment of  a  separate  Bureau  of  Tuberculosis,  whose  duty  should 
be  the  development  of  municipal  tuberculosis  work.  This  Bureau 
has  taken  over  and  gradually  developed  five  dispensaries,  with  a 
staff  of  twenty-four  visiting  tuberculosis  nurses,  and  paid  physi- 
cians, besides  the  director  and  office  force.  The  work  in  Cleveland 
is  centralized  in  its  Health  Department. 

General  dispensaries  are  required  to  refer  all  cases  of  tuber- 
culosis to  the  tuberculosis  dispensaries,  and  physicians  are  re- 
quired to  report  all  cases  to  the  Health  Department.  On  report 
cards  and  sputum  blanks  is  the  statement:  "All  cases  of  tuber- 
culosis reported  to  the  department  will  be  visited  by  a  nurse  from 
this  department  unless  otherwise  requested  by  the  physician." 
With  very  few  exceptions  the  physicians  are  glad  to  have  a  nurse 
call,  and  every  effort  is  made  to  co-operate  with  the  physicians  in 
handling  the  case. 

The  city  is  divided  into  five  districts,  with  a  dispensary  located 
in  each  district.  Patients  are  treated  only  at  the  dispensary  serv- 
ing the  district  in  which  they  live.  "This  plan  prevents  cases  wan- 
dering from  one  clinic  to  another  and  enables  the  nursing  force  to 
do  more  intensive  work  in  each  district." 

Once  a  week  the  chief  of  the  Bureau  of  Tuberculosis  and  the 
Superintendent  of  Nurses  meet  with  each  separate  dispensary  staff, 
and  cases  are  carefully  considered  and  work  discussed.  In  addition, 
meetings  of  the  active  nursing  staff  are  held,  informal  talks  on  tu- 
berculosis being  given,  or  the  work  of  allied  organizations  studied, 
speakers  coming  from  the  Associated  Charities,  Department  of 
Health,  Settlement  Houses,  etc.  Each  nurse  is  held  responsible 
for  the  handling  of  every  individual  case  in  her  district.  By  thus 
making  the  nurse  responsible,  the  interest  in  her  work  is  increased 
and  much  better  results  are  obtained.  If  the  problem  presented  is 
one  that  will  take  more  time  and  energy  than  the  busy  dispensary 
nurse  can  give,  it  is  referred  to  a  Special  Case  Committee. 

All  dispensary  cases  are  visited  in  the  home  within  twenty- 
four  hours  after  the  first  visit  to  the  dispensary,  where  a  complete 
history  of  the  case  is  taken.  The  patient  and  family  are  instructed 
and  each  member  urged  to  come  to  the  clinic  for  examination. 
Homes  where  a  death  from  tuberculosis  has  occurred  are  visited 
immediately,  with  the  consent  of  the  physician.  The  family  is 
carefully  instructed  as  to  disinfection,  and  advised  to  go  to  the 
physician  or  dispensary  for  examination. 

22 


Cleveland  nurses  wear  uniforms.  Each  nurse  carries  about 
three  hundred  patients,  a  very  small  percentage  being  bed  cases, 
usually  not  more  than  two  patients  at  a  time.  Nurses  receive  $60 
for  each  of  the  first  three  months;  $65  for  each  of  the  next  nine; 
$70  a  month  for  the  second  year ;  the  third  year  $80 ;  and  the  fourth 
year  $85. 
DETROIT 

The  Detroit  Board  of  Health  maintains  a  staff  of  ten  visiting 
tuberculosis  nurses.  They  give  a  small  percentage  of  bedside  care, 
wear  a  uniform,  and  receive  $1,000  per  year.  They  work  in  con- 
nection with  the  Board  of  Health  Dispensary  and  have  the  same 
general  follow-up  plan  as  other  cities. 

MILWAUKEE 

The  head  of  the  Division  of  Tuberculosis  of  the  Milwaukee 
Health  Department  is  a  trained  nurse.  She  has  six  field  nurses 
under  her,  each  handling  about  100  patients.  Nurses  are  in  uni- 
form, give  bedside  care  when  necessary,  and  receive  $900  per 
year.  The  dispensaries  are  operated  jointly  by  the  Health  Depart- 
ment and  private  charities.  Each  case  of  tuberculosis  reported  to 
the  Department  is  turned  over  to  a  nurse,  who  visits  the  physican 
to  see  whether  or  not  he  wishes  the  help  of  the  Department.  If  he 
does,  the  nurse  instructs  the  patient  and  family,  arranges  for  the 
patient's  removal  to  a  sanatorium  upon  the  physician's  advice,  at- 
tends to  disinfection  of  premises  and  examination  of  remaining 
members  of  family.  If  the  family  is  in  need  of  material  relief  she 
arranges  for  a  pension.  All  returned  sanatorium  cases  are  kept 
under  the  supervision  of  this  staff. 

ST.  LOUIS 

The  St.  Louis  Society  for  the  Relief  and  Prevention  of  Tuber- 
culosis has  a  staff  of  seven  nurses,  a  social  service  department,  a 
relief  department,  and  an  employment  bureau.  Conferences  of 
nurses  and  workers  are  held  three  times  a  week,  the  social  workers 
assuming  the  various  problems  met  by  the  nurses  in  their  daily 
work.  St.  Louis  nurses  carry  on  an  average  100  patients  each, 
about  25  %  being  bed  cases.  Nurses  are  in  uniform,  and  receive 
from  $60  to  $75  per  month.  Patients  report  to  the  City  Dispensary 
or  to  the  Washington  University  Dispensary,  and  the  usual  plan 
of  home  supervision  is  in  force. 

ATLANTA 

Atlanta,  Ga.,  has  a  staff  of  four  nurses  and  a  dispensary  under 
the  Atlanta  Anti-Tuberculosis  and  Visiting  Nurse  Association.  They 

23 


seem  to  have  a  particularly  well  organized  plan  of  work,  very  hearty 
co-operation  from  the  entire  city  (although  the  city  government 
has  appropriated  nothing  for  the  work),  and  are  doing  much  good 
along  lines  of  prevention,  with  dental,  and  nose  and  throat  clinics, 
and  open  air  schools.  They  have  had  difficulty  in  obtaining  nurses 
with  social  training,  and  have  been  at  some  pains  to  arrange  a 
social  service  training  school,  the  program  of  which  seems  very 
admirable. 


According  to  the  latest  report  of  the  National  Association  for 
the  Study  and  Prevention  of  Tuberculosis,  there  are  4,000  visiting 
tuberculosis  nurses  in  the  United  States.  There  are  more  than  400 
special  tuberculosis  clinics  as  compared  with  222  in  1909.  This 
paper  deals  with  only  a  few  of  the  larger  cities. 

There  are  many  other  cities  and  small  towns  having  tuber- 
culosis nurses  doing  work  well  worthy  of  mention.  Several  states 
have  adopted  the  plan  of  carrying  on  the  work  by  visiting  nurses 
in  each  county.  These  nurses  have  a  wide  field,  and  are  accom- 
plishing much  along  educational  lines,  the  territory  which  they  have 
to  cover  making  any  great  amount  of  actual  nursing  impossible. 
It  is  interesting  to  note  their  varied  experiences.  We  read  of 
patients  prepared  and  sent  to  sanatoria  and  hospitals,  the  family 
and  neighborhood  protesting  against  every  step ;  of  county  agents, 
churches,  lodges  or  communities  called  upon  to  assist  in  caring  for 
families;  of  long  drives  into  the  country  to  inspect  and  practically 
reorganize  some  home  where  several  members  have  died,  or  are 
dying  with  tuberculosis ;  of  repeated  admonitions  to  keep  windows 
open  in  rural  communities,  "where  the  air  is  pure  because  all  the  bad 
air  is  kept  closed  up  in  the  homes  and  school  houses."  When  the 
city  tuberculosis  nurse  reads  of  all  this,  she  feels  like  taking  off  her 
hat  to  the  rural  tuberculosis  visiting  nurse  and  wishing  her  success 
and  fair  weather. 

CHICAGO 

The  history  of  the  present  comprehensive  tuberculosis  work  in 
Chicago  is  closely  interwoven  with  the  history  of  the  Chicago  Tu- 
berculosis Institute,  which  was  organized  in  January,  1906.  The 
Institute  succeeded  the  Committee  on  Tuberculosis  of  the  Visiting 
Nurses'  Association  (the  pioneer  Tuberculosis  Committee  in  Chi- 
cago). 

The  Chicago  Tuberculosis  Institute  gives  the  following  as  its 
chief  aim :  "The  collection  and  dissemination  of  exact  knowledge  in 
regard  to  the  causes,  prevention  and  cure  of  tuberculosis."  The 

24 


progress  made  in  the  tuberculosis  situation  of  this  city  in  the  last 
seven  years  is  directly  due  to  the  systematic  campaign  of  the  Insti- 
tute. By  exhibits,  lectures,  literature,  stereopticon  views  and  mov- 
ing picture  films,  the  Institute  was  energetically  spreading  during 
these  years  the  knowledge  concerning  tuberculosis  and  its  proper 
methods  of  prevention. 

In  the  winter  of  1906-07  a  small  and  unpretentious  sanatorium 
called  "Camp  Norwood"  was  built  on  the  grounds  of  the  Cook  County 
Institutions  at  Dunning,  with  a  total  capacity  of  20  beds.  The 
Edward  Sanatorium  at  Naperville,  made  possible  by  the  munificence 
of  Mrs.  Keith  Spalding,  was  under  construction  at  the  same  time 
and  was  later  made  a  department  of  the  Chicago  Tuberculosis  Insti- 
tute. The  Edward  Sanatorium  was  the  chief  factor  in  demon- 
strating and  convincing  this  community  that  tuberculosis  can  be 
successfully  treated  in  our  climate. 

In  1907,  the  Chicago  Tuberculosis  Institute  established  a  sys- 
tem of  dispensaries  with  a  corps  of  attending  physicians  and  nurses. 
The  purpose  was  given  as  follows: 

(a)  Early  diagnosis  of  tuberculosis. 

(b)  Control  of  tuberculosis  by  means  of  personal  instruction 
and  home  visits. 

(c)  Education  of  the  community  in  the  necessity  of  further 
development  of  the  dispensary  and  nursing  systems. 

(d)  Spread  of  the  gospel  of  fresh  air  and  "right  living." 
Dispensaries  were  opened  during  the  latter  part  of  1907  as 

follows : 

(1)  Jewish  Aid  Society  Tuberculosis  Clinic  in  existence  since 
1900;  joined  the  Chicago  Tuberculosis  Institute,  Decem- 
ber 13th,  1907. 

(2)  Olivet  Dispensary,  May  15,  1907;  transferred  to  Poli- 
clinic in  December  of  same  year. 

(3)  Central  Free  Dispensary  at  Rush  Medical  College,  No- 
vember 16th. 

(4)  Northwestern  Tuberculosis  Dispensary,  November  21st. 

(5)  Hahnemann  Tuberculosis  Dispensary,  December  9th. 

(6)  Policlinic  Tuberculosis  Dispensary,  December  13th. 

(7)  West  Side  Dispensary  at  the  College  of  Physicians  and 
Surgeons,  December  17th. 

The  South  West  Dispensary  was  opened  in  August,  1909. 

The  underlying  and  controlling  belief  of  the  Chicago  Tubercu- 
losis Institute  has  always  been  that  no  great  progress  can  be  made 
in  the  campaign  against  tuberculosis,  or  in  any  other  reform  move- 
ment, until  the  soil  is  sufficiently  prepared.  The  soundness  of  this 

25 


policy  may  be  seen  in  the  fact  that  the  activities  of  the  Institute,  its 
exhibits,  more  especially  the  success  of  the  Edward  Sanatorium,  and 
also  the  work  of  the  dispensaries,  led  finally  to  the  adoption  by  the 
City  of  Chicago  of  the  Glackin  Municipal  Sanitarium  Law  and  made 
possible  the  Municipal  Tuberculosis  Sanitarium  now  nearing  com- 
pletion. 

The  maintenance  of  the  seven  dispensaries  having  become  a 
source  of  considerable  expense  to  the  Institute,  they  were  turned 
over  to  the  city  and  became  a  part  of  the  Municipal  Tuberculosis 
Sanitarium  in  September,  1910. 

The  Institute  continued  its  activities  as  "an  educational  insti- 
tution for  the  collection  and  dissemination  of  exact  knowledge  in 
regard  to  the  causes,  prevention  and  cure  of  tuberculosis."  It  con- 
cerns itself  also  with  keeping  before  the  minds  of  the  public  the 
proper  standard  of  care  for  the  tuberculous  in  public  and  private 
institutions.  Through  its  Committee  on  Factories,  the  Institute 
conducted  during  the  last  three  years  a  vigorous  campaign  for  the 
adoption  of  the  principle  of  medical  examination  of  employes.  The 
Robert  Koch  Society,  an  organization  of  physicians,  is  the  out- 
growth of  the  Institute.  In  brief,  the  Institute  for  years  has  led 
the  fight  against  tuberculosis  in  this  city. 

The  dispensary  system  of  the  Municipal  Sanitarium,  organized 
as  above  stated,  has  gradually  developed  into  ten  dispensaries  with 
a  superintendent  of  nurses,  ten  head  nurses  and  fifty  field  nurses. 
A  staff  of  thirty-one  paid  physicians  are  a  part  of  the  organization. 
The  ten  dispensaries  hold  twenty-six  clinics  a  week.  In  1913,  the 
attendance  at  the  Municipal  Tuberculosis  Sanitarium  clinics  was 
43,989  patients.  Nurses  made  in  all  39,737  visits  to  the  homes 
of  the  tuberculous  patients.  The  system  of  visiting  tuberculosis 
nursing  in  Chicago  is  steadily  moving  toward  greater  efficiency  in 
coping  with  the  existing  situation.  The  chief  features  of  the 
Chicago  arrangement  are  as  follows: 
(1)  Nurses  are  classified  into: 

Grade  II.    Field  Nurse 

Group  C  $  900.00 

Group  B  (At  least  one  year's  service  in  lower 

group)  960.00 

Group  A   (At  least  one  year's  service  in  next 

lower  group)  1080.00 

Grade  III.    Head  Nurse 

Group  B 1200.00 

Group  A  (At  least  one  year's  service  in  lower 

group)  1320.00 

26 


Supervising  Nurse 

Group  B 1440.00 

Group  A  (At  least  one  year's  service  in  lower 

group) 1560.00 

Grade  IV.    Superintendent  of  Nurses 

Group  D  :y 1920.00 

Group  C  (At  least  one  year's  service  in  lower 

group)  , 2100.00 

Group  B  (At  least  one  year's  service  in  next 

lower  group)   2280.00 

Group  A  (At  least  one  year's  service  in  next 

lower  group)  2400.00 

(2)  Civil  Service  examinations  for  all  of  the  above  positions  ren- 

der possible  the  selection  of  the  best  candidates. 

(3)  Efficiency  of  the  nursing  force  is  stimulated  by  conferences 

of  various  groups  of  nurses: 

(a)  Weekly  conferences  of  junior  nurses. 

(b)  Weekly  conferences  of  head  nurses. 

(c)  Conferences  of  the  entire  nursing  force  twice  a 
month. 

(d)  A  well  organized  system  of  lectures  on  various 
phases  of  tuberculosis  by  authorities. 

(e)  Bi-monthly  meetings  of  the  Nurses'  Tuberculosis 
Study  Circle,  the  proceedings  of  which  are  pub- 
lished in  this  pamphlet. 

(4)  A  centralized  system  of  administration,  with  brief  medical  and 

social  records  of  all  dispensary  cases  for  the  purpose  of 
clearing  and  information,  in  the  office  of  the  Superinten- 
dent of  Nurses  located  in  the  down  town  General  Offices 
of  the  Sanitarium. 

(5)  Nurses  wear  uniforms  beginning  with  the  middle  of  October  of 

this  year  (1914). 

(6)  Before  January,  1915,  all  tuberculosis  cases  in  their  homes  will 

be  cared  for  by  the  Municipal  Tuberculosis  Sanitarium. 

This  includes  both  far  advanced  and  surgical  cases. 
The  Chicago  Anti-tuberculosis  movement  has  been  more  for- 
tunate in  its  development  than  that  in  other  cities  where  the  dis- 
pensaries are  under  one  organization  and  the  nurses  under  an- 
other. Here  the  dispensaries  and  their  nursing  and  medical  staffs 
have  steadily  developed  under  the  same  direction,  the  advantages 
of  such  an  arrangement  being  clearly  evident. 

We  look  into  the  future  with  confidence.    The  Chicago  Munic- 
ipal Tuberculosis  Sanitarium,  with  its  900  beds  and  its  compre- 

27 


hensive  medical  and  laboratory  facilities  for  the  study  and  treat- 
ment of  cases,  is  to  open  before  the  year  1914  expires.  The  County 
Tuberculosis  Hospitals  for  advanced  cases  are  undergoing  a  revolu- 
tionary change  in  the  direction  of  administrative  and  medical  ef- 
ficiency. The  Dispensary  Department  of  the  Municipal  Tuberculosis 
Sanitarium  is  extending  sanatorum  care  to  the  homes  of  tuberculous 
patients  by  building  and  remodelling  porches  and  supplying,  ir 
necessary,  all  equipment  required  for  outdoor  sleeping..  We  have 
eighteen  open  air  schools.  We  have  an  effective  tuberculosis  exhibit. 
The  principle  of  early  detection  of  illness  is  being  adopted  by  many 
business  concerns  and  the  sanitary  conditions  are  gradually  improving. 
The  future  is  full  of  promise. 


28 


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CQ 

PROVISIONS  FOR  OUT-DOOR  SLEEPING 


By  MAY  MacCONACHIE,  R.  N. 

Head  Nurse,  St.  Elizabeth  Dispensary  of  the  Chicago  Municipal 
Tuberculosis  Sanitarium. 


In  the  treatment  of  tuberculosis,  the  best  results  have  been 
obtained  in  sanatoria.  In  most  cities,  however,  sanatorium  treat- 
ment is  not  possible  for  many  patients;  consequently  home 
treatment  must  be  provided.  This  can  be  done  most  successfully 
when  we  imitate  as  far  as  possible  the  sanatorium  method.  This 
paper  describes  some  of  the  arrangements  for  out-door  sleeping 
which  may  be  provided  for  a  patient  taking  the  "cure"  at  home. 

The  Fresh  Air  Room. 

Select  the  best  lighted  and  best  ventilated  room,  preferably 
one  with  southern  exposure,  for  the  patient  to  sleep  in.  All  super- 
fluous furniture  and  hangings  should  be  removed.  In  doing  this, 
however,  the  room  need  not  be  made  cheerless;  small  rugs,  wash- 
able curtains  and  one  or  two  cheerful  pictures  may  be  allowed. 

There  should  be  some  means  of  securing  cross  ventilation  in  all 
sleeping  rooms,  as  for  the  ideal  fresh  air  room  this  is  most  essen- 
tial. When  this  cannot  be  arranged  and  when  there  are  windows 
only  on  one  side  of  the  room  and  a  transom  is  lacking,  the  window 
should  be  open  at  both  upper  and  lower  sash.  This  arrangement 
allows  the  bad  air  to  escape  through  the  opening  at  the  top,  while 
the  fresh  air  enters  below.  The  "French  window"  which  opens 
from  floor  to  ceiling  by  swinging  inward  is  to  be  recommended  for 
the  ideal  sleeping  room.  In  ventilating  a  room  which  is  used  for  a 
sitting  room  in  the  daytime,  especially  in  stormy  weather,  it  is 
sometimes  necessary  to  protect  the  patient  from  a  direct  draft. 
For  this  purpose  a  shield  may  be  made  from  an  ordinary  piece  of 
hardwood  board,  eight  inches  wide  (or  larger)  and  long  enough  to 
fit  in  between  the  side  casings.  It  can  be  covered  with  wire  netting, 
cheese  cloth  or  muslin.  There  are  a  variety  of  wind  shields  on  the 
market  called  sash  ventilators,  or  air  deflectors. 

30 


Window  Tents 

In  the  treatment  of  tuberculosis  the  window  tent  was  originally 
devised  to  give  fresh  air  to  patients  in  their  own  rooms.  To  a  poor 
family  the  window  tent  has  an  economic  advantage,  especially  if 
the  room  where  the  patient  lies  serves  as  a  living  room  for  the  rest 
of  the  family.  The  fact  that  the  well  members  should  not  shiver  is  of 
vital  importance  in  many  respects.  A  simple  home  window  tent, 
and  one  which  can  be  made  easily  in  the  homes  of  the  poor,  consists 
of  a  straight  piece  of  denim  or  canvas  hung  from  the  top  of  the 
window  casing  and  attached  to  the  outer  side  of  the  bed.  The 
space  between  this  and  the  window  casing  on  each  side  is  closed 
with  the  same  material  properly  cut  and  fitted.  Ten  to  twelve 
yards  of  cloth  is  necessary.  If  made  of  denim,  the  price  of  the 
tent  would  be  about  $3.00 ;  if  of  canvas,  about  $4.50.  If  this  cannot 
be  obtained,  take  two  large,  heavy  cotton  sheets,  sew  them  to- 
gether along  the  edge,  tack  one  end  to  the  top  of  the  window 
casing  and  fasten  the  other  end  to  the  bed  rail  with  tape.  There 
will  be  enough  cloth  hanging  on  each  side  to  form  the  sides  of  the 
tent,  and  this  should  be  tacked  to  the  window  casings.  The  manu- 
factured window  tents  are  all  constructed  practically  on  the  same 
principle.  The  difference  between  them  is  in  their  shape  and  the 
manner  of  their  operation.  There  are  two  types:  the  awning 
variety,  as  illustrated  by  the  Knopf  and  the  Allen  tents ;  and  those  of 
the  box  order,  of  which  the  Farlin,  Walsh,  Mott  and  Aerarium  are 
examples. 

KNOPF  WINDOW  TENT.  The  Knopf  window  tent*  is  constructed 
of  four  Bessemer  rods  furnished  with  hinged  terminals,  the 
hinges  operating  on  a  stout  hinge  pin  at  each  end  with  circular 
washers  so  that  it  can  be  folded  easily.  The  frame  is  covered  with 
yacht  sail  twill.  The  ends  of  the  cover  are  extended  so  they  can 
be  tucked  in  around  the  bedding.  The  tent  fills  half  of  the  window 
opening  and  can  be  attached  to  the  side  casings  three  inches  below 
the  center  of  the  sash,  this  space  being  for  ventilation.  The 
patient  enters  the  bed  and  then  the  tent  is  lowered  over  him,  or 
he  can  lower  the  tent  himself  by  means  of  a  small  pulley  attached 
to  the  upper  portion  of  the  window.  The  bed  can  be  placed  by 
the  window  to  suit  the  patient's  preference  for  sleeping  on  his 
right  or  left  side.  A  piece  of  transparent  celluloid  is  inserted  in 
the  middle  of  the  inner  side  so  that  the  patient  can  look  into  the 
room  or  can  be  watched. 

ALLEN  WINDOW  TENT.  The  Allen  window  tentf  is  on  the 
same  order  as  Knopf's,  the  difference  being  chiefly  in  size.  The 

*For  illustration,  see  Knopf,   "Tuberculosis,"  Chap.  IV,   page  67. 
tSee  Carrington,  "Fresh  Air  and  How  to  Use  It,"  Chap.  II,  page  29. 

31 


Allen  tent  covers  the  entire  window  and  has  the  appearance  of 
an  ordinary  window  awning  turned  into  the  room,  ventilation  being 
secured  from  openings  above  the  upper  and  below  the  lower  sash. 

Box  WINDOW  TENT.  The  box  variety  of  window  tent  con- 
sists of  a  light  steel  frame  covered  with  canvas  or  cloth.  The 
frame  fits  between  the  window  casing  like  a  wire  screen  frame. 
The  bottom,  through  which  the  head  is  passed,  can  be  made  of 
flannel  and  can  be  drawn  closely  around  the  neck. 

AERARIUM.  Dr.  Bull's  aerarium*  is  another  device  similar 
to  a  window  tent.  This  arrangement  consists  of  a  double  awning 
supported  on  a  wooden  or  steel  frame  and  attached  to  the  outside 
of  the  window  with  a  special  ventilating  arrangement.  The  head 
of  a  cot  bed  is  put  through  the  window  and  the  patient's  head 
rests  out  of  doors.  The  lower  window  sash  must  be  raised  about 
two  feet  and  a  heavy  cloth  or  curtain  hung  from  its  lower  edge 
so  that  it  will  drop  across  the  body  and  shut  off  the  room  from 
the  outside  air. 

Window  tents  have  a  few  advantages.  The  patient's  prolonged 
rest  in  bed  will  be  more  endurable  when  he  is  permitted  to  look 
out  on  the  street  and  watch  life  than  when  obliged  to  gaze  at 
the  four  walls  of  his  room.  Also  patients,  who  can  be  persuaded 
only  with  difficulty  to  sleep  with  the  window  wide  open,  will  not 
hesitate  when  they  have  this  tent  as  an  inducement.  Draft  which 
the  patient  usually  dreads,  particularly  in  cold  weather  and  when 
he  perspires,  need  not  be  feared  when  sleeping  in  a  window  tent. 
Further,  this  limits  the  possible  infection  to  the  interior  of  the 
window  tent,  which  is  obviously  an  advantage.  While,  as  a  matter 
of  course,  the  patient  will  have  been  taught  to  always  hold  his 
napkin  before  his  mouth  when  he  coughs  or  sneezes,  this  is  not 
always  done,  and  cannot  be  done  when  coughing  in  sleep.  The 
constant  exposure  to  air  and  light  of  the  bacilli,  which  may  have 
been  expelled  with  the  saliva  and  remain  adhered  to  the  canvas, 
will  soon  destroy  them.  Also  the  canvas  of  the  tent  is  attached 
to  the  frame  by  simple  bands  and  its  removal  from  the  frame  for 
thorough  cleansing,  washing  and  disinfection  is  thus  made  easy. 

Tents 

Tents  are  frequently  used  for  open  air  living.  However,  they 
are  not  to  be  recommended  for  those  who  can  afford  to  construct 
open  buildings  of  more  durable  material.  Ordinary  tents  hold 
odors.  They  are  often  very  hard  to  ventilate;  for  a  strong  draft 
is  produced  when  the  flaps  are  open.  There  is  no  ventilation 


•For  illustration,  see  Carrlngton,  "Fresh  Air  and  How  to  Us«  It,"  Chap.  II,  pag«  37. 

32 


through  the  canvas,  as  it  is  impenetrable  by  currents  of  air.  In 
order  to  make  a  tent  comfortable  for  a  sick  person  it  should  have 
a  large  fly  forming  a  double  roof  with  an  air  space  between,  a 
wide  awning  in  front  where  the  patient  can  sit  during  the  day, 
a  board  floor  laid  at  least  a  few  inches  above  the  ground,  and  the 
sides  boarded  up  two  or  three  feet  from  the  floor.  Many  modi- 
fications of  the  ordinary  tent  have  been  made  for  the  purpose  of 
obtaining  a  well  ventilated  canvas  shelter. 

GARDNER  TENT.  The  Gardner  tent*  is  conical  in  shape  with 
octagonal  floor  area,  with  an  opening  in  the  center  of  the  roof 
and  one  at  the  bottom  between  the  floor  and  the  sides.  These 
openings  act  like  a  fireplace  and  produce  a  constant  upward  current 
of  air  through  the  interior.  "The  floor  is  in  six  sections  and  can 
be  bolted  together.  It  is  made  of  Ix4-inch  tongued  and  grooved 
boards  supported  eight  inches  above  the  ground  on  2x4-inch  joists. 
Around  the  edge  of  the  floor  is  a  wainscoting  of  narrow  floor  boards 
four  feet  in  height.  There  is  no  center  pole,  as  the  tent  is  sup- 
ported by  an  eight-sided  wooden  frame.  The  roof  and  sides  are 
of  khaki  colored  duck.  The  lower  edge  of  the  canvas  walls  are 
fastened  several  inches  below  the  floor  and  one  inch  out  from  the 
wainscoting  on  all  sides.  This  leaves  an  opening  through  which  a 
gradual  inflow  of  air  is  obtained  without  causing  a  draft.  The 
opening  in  the  center  of  the  roof  is  one  foot  in  diameter  and  is 
covered  with  a  zinc  cap."  The  cap  is  raised  or  lowered  by  a  pulley 
attachment. 

TUCKER  TENT.  The  Tucker  tent  is  similar  to  the  Gardner 
in  that  it  is  supplied  with  ventilation  in  the  wainscoting  near  the 
floor  and  in  the  center  of  the  roof.  It  is  rectangular  rather  than 
octagonal  in  shape  and  is  made  in  two  sizes — one,  eight  feet  wide 
by  ten  feet  long,  and  the  other,  twelve  feet  wide  by  fourteen  feet 
long.  It  has  a  wooden  floor,  wooden  base  and  canvas  side,  with 
window  openings  on  each  side.  "The  canvas  above  the  base 
in  the  front  is  attached  to  awning  frames  so  that  it  can  be  raised 
or  removed  altogether  for  the  free  entrance  of  air  and  light."  The 
roof  and  fly  are  made  of  12-ounce  army  duck. 

LA  POINTE  TENT.  The  La  Pointe  tent  is  similar  to  the  Tucker 
tent.  It  is  a  canvas  cottage  with  doors,  windows  and  floor.  The 
top  is  made  of  canvas,  with  a  fly  which  projects  two  inches  on  all 
sides.  The  windows  have  a  wire  netting  and  canvas  shutters,  the 
canvas  being  so  arranged  that  it  can  be  pulled  up  as  a  curtain,  or 
extended  as  an  awning.  Its  cost  is  $85  to  $100. 

•For  illustration,   see   Carrington,   "Fresh   Air   and   How   to   Use   It,"   Chap.   VIII, 
page  128. 

33 


ARMY  TENT.  A  simple  ordinary  tent  is  the  United  States 
Army  tent.  There  are  two  different  styles,  one  with  closed  corners 
and  one  with  open  corners.  It  is  made  of  army  duck  with  poles, 
stakes  and  guys,  and  costs  according  to  size.  A  small  tent  eight 
feet  four  inches  long  and  six  feet  eleven  inches  wide  would  cost 
$7.50,  and  lumber  for  floor  about  $2.00  extra.  This  tent  is  easily 
put  up,  care  being  taken  to  select  a  dry  soil,  places  where  the 
water  stands  in  hollows  after  a  rain  should  be  avoided.  A  small 
trench  about  one  foot  deep  around  the  tent  will  help  in  keeping  the 
soil  dry. 

TENT  COT.  For  experimenting  in  outdoor  sleeping  a  tent 
cot  is  a  very  simple  arrangement.  It  consists  of  a  plain  canvas 
cot  with  a  frame  supporting  a  small  tent.  Ventilation  is  secured 
by  openings  at  both  ends ;  also  at  the  side  where  the  patient  enters. 
These  openings  are  covered  with  flaps  which  can  be  opened  or 
closed.  It  is  light,  weighing  from  twenty  to  fifty  pounds,  and  its 
position  and  exposure  can  be  conveniently  changed.  The  cost  is  $9. 

KNOPF'S  HALF  TENT.  Another  simple  arrangement  is  Knopf's 
half  tent.*  It  consists  of  a  frame  of  steel  tubing  covered  with  sail 
duck  and  secured  with  snap  buttons  on  the  inside.  It  is  used  for 
patients  sitting  out  of  doors.  The  reclining  chair  is  placed  in  the 
tent  with  its  back  to  the  interior.  Its  weight  helps  to  hold  down 
the  floor  bracing  attached  to  the  frame. 

Sleeping  Porches 

One  of  the  most  important  arrangements  for  outdoor  sleeping  is 
the  sleeping  porch.  To  be  convenient,  it  should  have  an  entrance 
from  a  bedroom  and,  when  possible,  from  a  hall ;  for  every  outdoor 
sleeper  should  have,  during  cold  weather,  a  warm  apartment  in 
connection  with  his  open  air  sleeping  room.  The  best  exposure 
in  Illinois  is  south,  southeast  or  east.  Sleeping  out  should  be  a 
permanent  thing  during  all  seasons.  The  sleeping  porch  must  be 
kept  neat  and  attractive.  A  cot  placed  between  the  oil  can  and 
the  washtub  on  a  dingy  back  porch  is  very  dismal  and  bound  to 
have  a  depressing  effect  on  the  sleeper. 

It  costs  very  little  to  arrange  an  ordinary  sleeping  porch  pro- 
vided you  have  the  porch  to  begin  with.  If  a  porch  is  fairly  deep 
and  sheltered  on  two  sides  by  an  angle  of  the  house,  sufficient 
protection  for  moderately  cold  weather  can  usually  be  obtained 
by  canvas  curtains  tacked  to  wooden  rollers.  These  can  be  raised 
and  lowered  by  means  of  ropes  and  pulleys,  the  bed  being  placed 
so  that  the  wind  will  not  blow  strongly  on  the  patient's  head. 

•For  illustration,   see  Knopf,  "Tuberculosis,"  Chap.  IV,   page  58. 

34 


ORDINARY  PORCHES.*  A  useful  porch  can  be  built  for  $15 
to  $25  with  cheap  or  second-hand  lumber,  and  if  only  large  enough 
to  receive  the  bed  and  a  chair  will  still  be  effective  for  the 
outdoor  treatment.  The  roof  can  be  made  with  canvas  curtain, 
or  a  few  boards  and  some  tar  paper.  The  end  most  exposed  to  the 
wind  and  rain  and  the  sides  below  the  railing  should  be  tightly 
boarded  to  prevent  drafts. 

Second  or  third  story  porches  are  supported  from  the  grountf 
by  long  4x4-inch  posts,  or  when  small  they  can  be  held  by  braces 
set  at  an  angle  from  the  side  of  the  house.  When  the  long  posts 
are  used  they  are  all  placed  six  feet  apart  and  the  space  between 
them  is  divided  into  three  sections  by  2x4-inch  timbers.  The 
interior  is  protected  by  canvas  curtains  fastened  to  the  roof  plate 
and  arranged  so  as  to  be  raised  or  lowered  by  ropes  and  pulleys. 
These  curtains  are  made  about  six  feet  wide  and  fit  in  between 
the  supporting  posts  and  rest  against  the  smaller  timbers.  This 
arrangement  keeps  the  curtains  firm  during  a  storm,  as  both  rollers 
and  canvas  can  be  securely  tied  to  the  frames.  This  porch  would 
cost  between  $30  and  $50. 

PORCH  DE  LUXE.  When  a  bed  on  a  porch  is  not  in  use  it  is  often 
unsightly  and  in  the  way,  while  in  winter,  unless  well  protected, 
the  bed  clothes  and  bedding  become  damp.  In  order  to  overcome 
this,  the  Porch  de  Luxe*  has  recently  been  devised.  This  consists 
of  a  low-built  bedstead  arranged  to  slide  through  an  opening  in 
the  wall  of  the  house  between  the  porch  and  bedroom. 

SLEEPING  CABIN.  To  lessen  the  disadvantages  of  the  high 
roofed,  windy  porch,  the  home-made  sleeping  cabin  is  to  be  recom- 
mended. This  cabin  is  built  on  the  porch.  The  frame  is  braced 
against  the  side  of  the  house  and  rests  on  the  floor  of  the  porch, 
but  the  top  of  the  cabin  is  much  lower  than  the  roof  of  the  porch. 
The  frame  consists  of  2x4-inch  timbers.  The  sides  and  roof  are  of 
canvas  curtains;  these  can  be  rolled  up  separately.  Some  of 
these  cabins  have  had  the  roof  hinged  so  that  it  can  be  raised  in 
warm  weather.  The  greatest  advantage  of  the  cabin  is  the  control 
of  the  weather  situation.  The  cost  is  $15  to  $20.f 

KNOPF'S  STAR-NOOK.  Another  arrangement  is  Knopf's  "Star- 
nook.'^  This  is  a  wall  house  supported  by  the  roof  of  an  extension, 
or  on  a  bracket  attached  to  the  wall  of  the  building.  This  fresh  air 
room  consists  of  a  roof,  floor  and  three  walls  and,  with  the  exception 
of  the  roof  and  the  floors,  is  built  of  steel  frames  holding  movable 
shutters.  It  is  nine  feet  long  by  six  feet  deep,  the  height  being 

•For  illustration,  see  Carrlngton,  "Fresh  Air  and  How  to  Use  It,"  Chap.  VII,  page  108. 

tFor  illustration,  see  Journal  of  Outdoor  Life,  January  1914. 

§For  illustration,  see  Carrington,  "Fresh  Air  and  How  to  Use  It,"  Chap.  IV,  page  55. 

35 


eight  feet  at  the  inner  side  with  a  fall  of  two  feet.  At  both  ends 
are  windows  which  can  be  opened  outward.  The  roof  can  be  raised 
entirely  off  the  apartment  by  means  of  a  crank.  Also  the  upper 
sections  of  the  front  windows  can  be  opened  or  closed.  Sometimes 
new  doors  or  windows  will  be  needed  to  give  access  to  a  desired 
position.  The  "Star-nook"  can  be  secured  with  safety,  and  when 
strongly  supported  there  need  be  no  fear  in  regard  to  its  stability. 

Roofs 

The  value  of  roof  space  for  outdoor  treatment  in  cities  is 
gradually  being  appreciated.  They  can  be  made  splendid  sites  for 
various  kinds  of  little  buildings.  The  roof  of  an  apartment  house 
offers  a  choice  of  situations,  but  there  are  different  conditions  to 
be  considered,  such  as  the  best  exposure  and  the  most  protected 
place,  one  that  cannot  be  overlooked  from  neighboring  buildings; 
also  security  from  severe  storms.  Tents  have  been  erected  upon 
the  roofs  of  city  buildings,  but  they  are  not  to  be  recommended 
for  such  positions  unless  they  can  be  placed  in  the  shelter  of  a 
strong  windbrake.  When  erected  upon  the  roof  of  high  buildings 
they  should  be  protected  on  two  sides  by  walls,  or  by  other  parts 
of  the  structure  upon  which  they  are  to  be  placed. 

A  cabin  is  most  desirable  for  the  roof.  In  its  construction 
it  is  best  to  use  a  wooden  frame  for  the  foundation.  It  can  then 
be  moved  and  its  position  and  exposure  changed  easily.  This  frame 
should  be  made  of  2x6-inch  planks  laid  flat  on  the  roof.  The 
upright  frame  and  siding  boards  for  the  back  and  sides  should  be 
of  2x4-inch  timbers.  The  front  of  the  cabin  should  be  left  open, 
but  arranged  with  a  canvas  curtain  tacked  on  a  roller  so  that  it  can 
be  closed  in  stormy  weather.  Tar  paper  is  used  for  the  roof.  When 
completed,  the  framework  should  be  braced  to  give  firmness.  If 
two  buildings  connect  and  one  is  taller  than  the  other  with  no 
space  between,  a  lean-to  cabin  is  most  desirable. 


With  the  devices  just  described  the  home  treatment  can  be 
secured  with  little  cost.  Patients  who  are  afraid  of  outdoor  sleeping 
should  begin  in  moderate  weather.  All  shelters  should  be  as  incon- 
spicuous as  possible.  In  choosing  a  suitable  position  for  a  fresh 
air  bedroom,  it  should  be  remembered  that  early  morning  sounds 
and  sunlight  should  be  eliminated,  if  possible.  This  can  sometimes 
be  done  by  selecting  a  room  far  from  the  street  and  by  shading  the 
bed  with  blinds.  One's  neighbor  should  be  taken  into  consideration, 
and  a  position  decided  upon  which  does  not  overlook  his  windows, 
porches  or  yards,  and  when  arranging  for  the  rest  cure  in  the 
reclining  chair  during  the  day  one  should  always  bear  in  mind  that 
it  is  much  more  agreeable  and  conducive  to  the  well-being  of  the 
patient  to  have  a  pleasant  view  to  look  upon. 

36 


SOME  POINTS  IN  THE  NURSING  CARE  OF 
THE  ADVANCED  CONSUMPTIVE 


By  ELSA  LUND,  R.  N. 

Head  Nurse,  Iroquois  Memorial  Dispensary  of  the  Chicago  Muni- 
cipal Tuberculosis  Sanitarium. 


The  problem  of  caring  for  the  advanced  consumptive  is  a  very 
complicated  one;  it  involves  not  only  the  patient,  but  the  whole 
family  as  well.  A  complete  rehabilitation  of  the  entire  family  is 
necessary  in  most  of  the  dispensary  cases. 

The  first  thing  the  nurse  must  do  is  to  gain  the  confidence  of 
both  the  patient  and  the  family.  The  chief  requisite  in  the  nursing 
of  the  advanced  consumptive  is  a  clean,  careful,  patient  and  sym- 
pathetic nurse.  Frequently  she  finds  her  patient  extremely  irri- 
table, and  often  this  mental  condition  has  affected  his  whole  family, 
or  whoever  has  been  associating  with  him.  A  painstaking,  sympa- 
thetic nurse  will  readily  understand  that  the  causes  for  this  state 
of  affairs  are  most  natural.  The  consumptive  may  have  spent 
wakeful  nights,  due  to  coughs  and  pains  and  distressing  expectora- 
tion; the  enforced  cessation  of  work  may  have  caused  pecuniary 
worries;  all  his  customary  pleasures  are  now  denied  him,  and  he 
has  strength  for  neither  physical  nor  mental  diversion.  Realizing 
this,  the  nurse  must  kindly  but  firmly  impress  upon  the  patient 
the  necessity  of  co-operation  and  the  danger  of  infecting  others 
and  of  reinfecting  himself.  She  should  at  once  create  a  more  cheer- 
ful atmosphere  by  repeated  suggestions  that  if  he  will  only  do  his 
duty  as  a  hopeful  patient,  he  will  not  be  considered  a  menace  by 
those  who  come  in  contact  with  him,  and  his  family  will  gladly 
associate  with  him. 

Next  comes  the  concrete  problems  which  the  nurse  must  solve. 
That  of  proper  housing  of  the  patient  is  one  of  the  most  important, 
and  especially  so  in  the  case  of  the  advanced  consumptive,  because 
of  the  greater  danger  of  spreading  the  infection  if  the  conditions 
are  unfavorable.  Where  it  is  necessary  that  the  family  should 
move,  the  nurse  should  assist  in  the  selection  of  a  new  home. 
If  possible,  a  detached  house  should  be  chosen,  affording  plenty 

37 


of  light  and  sunshine,  away  from  dusty  streets  and  roads.  Offen- 
sive drains  and  other  insanitary  conditions  should  be  avoided. 
The  water  supply  should  be  abundant  and  the  plumbing  in  good 
repair. 

The  room  of  the  patient  should  be  well  lighted  and  well  ven- 
tilated, and  preferably  have  a  southern  exposure.  Cross  ventilation 
is  very  desirable.  When  all  unnecessary  furniture  and  all  hangings 
and  bric-a-brac  have  been  removed,  and  the  old  paper  stripped  from 
the  walls,  the  walls  should  be  whitewashed,  or  covered  with  wash- 
able paper,  or  painted.  Painted  walls  are  inexpensive,  and  they 
have  the  further  advantage  that  they  can  be  washed  frequently. 
The  floor  should  be  bare  and  likewise  frequently  washed.  Simple 
furniture  is  commendable,  and  old  pieces  can  be  made  very  attrac- 
tive by  having  them  enameled.  Proper  furnishings  include  a  com- 
fortable bed  (one  made  of  iron  and  raised  on  wooden  blocks  makes 
nursing  care  easier),  a  bedside  table,  chairs,  a  rocking  chair,  a 
washstand,  and  even  a  couch  on  which  the  patient  could  be  placed 
occasionally  to  relieve  the  monotony.  Two  or  three  pictures  which 
can  be  readily  dusted  and  cleaned  will  brighten  the  bare  walls  one 
finds  in  what  are  generally  recommended  as  sanitary  rooms. 
Flowers  always  add  to  the  attractiveness  of  a  room,  and  when  the 
bed  is  placed  near  the  window  the  patient  is  given  the  opportunity 
of  enjoying,  to  some  extent,  at  least,  the  pleasures  of  out-of-doors. 
The  mattress  should  be  provided  with  a  washable  cover.  Strips 
of  muslin  sewed  across  the  tops  of  the  blankets  will  protect  them 
from  sputum,  in  case  the  sheets  happen  to  slip.  Soiled  bed  linen 
must  be  handled  as  little  as  possible,  soaked  in  water,  washed 
separately  and  boiled.  If  sputum-covered,  it  should  be  soaked  in  a 
five  per  cent  solution  of  carbolic  acid  or  a  solution  of  chloride  of  lime. 
Instead  of  dry  sweeping  and  dusting,  the  floors  should  be  washed 
with  soap  and  water  and  dusted  with  wet  cloths.  Great  care  should 
be  taken  in  instructing  and  demonstrating  to  the  family  how  to 
properly  care  for  the  room.  Special  attention  must  be  given  to 
the  bed,  its  comforts  and  its  cleanliness.  Every  nurse  is  familiar 
with  what  is  known  as  the  "Klondike"  bed,  and  it  is  unnecessary 
to  discuss  it  here  in  detail.  Since  both  patient  and  family 
derive  such  direct  benefit  from  a  constant  supply  of  fresh  air,  too 
much  attention  can  not  be  given  to  proper  ways  of  securing  it,  and 
at  the  same  time  keeping  the  patient  warm.  Where  bed  coverings 
are  limited,  warmth  can  be  secured  by  sewing  layers  of  newspapers 
between  two  cotton  blankets;  again,  sheets  of  newspapers  or  tar 
paper  keep  out  the  cold  to  a  great  extent.  Proper  ventilation  pre- 
vents night  sweats.  Means  of  heating  the  room  must  be  provided, 

38 


because  of  the  low  vitality  of  the  patient  and  the  need  of  frequent 
care. 

The  patient's  clothing  needs  to  be  light  but  warm ;  where  wool 
proves  irritating  to  the  skin,  a  heavy  linen  mesh  has  been  found  a 
good  substitute,  due  to  the  fact  that  it  dries  quickly  when  the 
patient  perspires.  The  patient  should  have  two  good  soap  and 
water  baths  a  week.  The  nurse  should  let  the  family  know  when 
she  is  coming  to  give  these  baths  and  explain  to  them  that  she 
expects  them  to  have  ready  for  her  towels,  soap,  clean  bed  linen, 
wash  basin,  wash  cloths,  newspapers  and  hot  water.  Night  sweats 
demand  careful  rubbing,  first  with  a  dry  towel;  vinegar  sponging 
is  found  to  be  very  effective;  alcohol  rubs  prevent  bed  sores. 

The  hair,  nails  and  teeth  require  special  attention ;  beards  and 
mustaches  should  be  shaved.  Every  patient  must  learn  to  use  the 
tooth  brush  after  meals,  that  the  mouth  may  be  kept  scrupulously 
clean.  Gargling  should  also  be  insisted  upon.  Tooth  brushes  can 
be  kept  in  a  50  per  cent  Dobell's  solution,  Liquor  Antiseptic  (U.  S. 
P.),  or  a  2  per  cent  solution  of  carbolic  acid  colored  with  vegetable 
green  coloring  matter  as  a  warning  against  swallowing.  As  an  aid 
in  hardening  the  gums,  all  foreign  deposits  should  be  removed,  the 
gums  massaged  by  the  patient  and  normal  salt  solution  used  as  a 
gargle.  Where  the  patient  is  suffering  from  pyorrhea,  the  gums 
may  be  painted,  on  the  order  of  the  physician,  with  tincture  of  iodine 
(U.  S.  P.)  or  a  2  per  cent  solution  of  copper  sulphate.  While  the 
patient  is  learning  to  cleanse  his  mouth  carefully  after  every  meal, 
he  may  also  be  instructed  to  avoid  placing  anything  in  his  mouth, 
except  food,  drink,  gargling  solution  or  tooth  brush.  The  reason  for 
using  some  kind  of  mouth  wash,  instead  of  merely  water,  is  because 
in  that  way  the  need  of  cleanliness  is  more  forcibly  impressed  upon 
the  patient. 

Such  matters  as  the  use  of  separate  dishes,  etc.,  are  so  well 
known  to  every  tuberculosis  nurse  that  it  is  unnecessary  to  dwell 
on  them  at  length  in  this  paper. 

Difficulties  always  arise  regarding  proper  method  for  the  care 
and  disposal  of  sputum.  The  following  are  some  of  the  plans 
adopted  by  tuberculosis  hospitals  for  advanced  cases: 

1.    Infirmary  of  Eudowood  Sanatorium,  Towson,  Maryland. 

Pasteboard  fillers  in  such  quantities  as  will  be  required 
during  the  current  day  are  issued  to  the  patients.  When 
the  filler  becomes  not  more  than  two-thirds  full,  it  is  care- 
fully filled  with  sawdust,  wrapped  in  a  newspaper,  tied 
with  a  cotton  cord  and  deposited  in  a  large  galvanized 

39 


iron  bucket,  in  which  it  is  carried,  with  the  others,  to  the 
incinerator. 

2.  North  Reading  (Mass.)  State  Sanatorium. 

A  room  specially  equipped  for  the  disposal  of  sputum 
is  recommended.  Paper  sputum  boxes  are  changed  twice 
daily,  inspected  as  to  character,  quantity  and  presence  of 
blood.  Then  the  box  is  filled  with  sawdust,  wrapped  in 
newspaper  and  carried  to  the  incinerator  for  burning. 

3.  Montefiore  Home  Country  Sanitarium,  Bedford  Hills,  N.  Y. 

In  cases  where  bed  patients  have  a  very  large  amount 
of  sputum,  large  cups  of  white  enamel  are  used,  with  a 
hinged  lid  that  lifts  readily.  The  sputum  is  from  there 
thrown  into  receptacles  containing  sawdust,  taken  to  the 
incinerator  and  burned  twice  daily.  Both  sputum  cups 
and  the  large  container  holding  sawdust  are  sterilized  by 
li ve  steam. 

4.  House  of  the  Good  Samaritan,  Boston,  Mass. 

Paper  handkerchiefs  and  bags  are  recommended  when 
the  quantity  of  sputum  is  small.  Burnitol  sputum  cups 
without  holders  are  used;  the  bottom  of  each  cup  holds 
a  small  amount  of  sawdust,  which  serves  the  purpose  of 
hindering  the  sputum  from  penetrating  through  the  cup. 
All  the  cups  are  carefully  tied  up  in  newspaper  by  the 
nurse  or  the  patient  before  they  are  sent  to  the  incinerator. 

5.  Chicago  Fresh  Air  Hospital. 

Paper  fillers  and  metal  holders  are  used.  The  fillers 
are  placed  in  a  large  can,  covered  with  sawdust,  and  then 
burned  in  the  incinerator.  The  holders  are  sterilized  daily. 
The  Hospital  recommends  paper  napkins  where  the  quan- 
tity of  sputum  is  small;  if  there  is  no  possible  means  of 
burning  the  sputum,  it  should  be  treated  with  a  strong 
solution  of  concentrated  lye  and  then  poured  into  the 
water  closet. 

The  chief  source  of  infection  is  undoubtedly  the  expectoration 
of  the  consumptive,  spread  by  careless  coughing  and  spitting.  Be 
very  emphatic  in  instructing  the  patient  to  cover  his  mouth  with  a 
paper  napkin  when  he  coughs  and  then  to  dispose  of  it  carefully 
in  such  a  way  that  no  particle  of  the  sputum  touches  either  his 
hands  or  his  face.  Insist  on  frequent  washing  of  the  hands. 

The  following  methods  and  solutions  are  employed  in  the  treat- 
ment of  laryngeal  tuberculosis  in  various  institutions : 

40 


North  Reading  (Mass.)  State  Sanatorium. 

The  following  are  used  as  gargles : 

Dobell's  solution;  Dobell's  solution  and  formalin  (one  drop  of 
formalin  to  an  ounce  of  solution) ;  alkaline  antiseptic  N.  F.  (one  to 
four  water) ;  salt  and  sodium  bicarbonate  (one  dram  of  salt  and 
two  drams  sodium  bicarbonate  to  a  pint  of  water). 

Sprays  used  at  this  institution  are  as  follows : 

Spray  No.  1.  Menthol  spray  in  proportion  of  fifteen  grains  of 
menthol  to  one  ounce  of  alboline. 

Spray  No.  2.  Menthol  (4  drams  plus  10  grains) ;  thymol  (7 
drams  plus  25  grains) ;  camphor  (7  drams  plus  25  grains) ;  liquid 
petrolatum  (64  ounces). 

Heroin  spray.  From  one  to  three  grains  of  heroin  to  one  ounce 
of  water. 

Cocaine  spray.  From  one-half  to  two  per  cent,  usually  before 
meals,  for  dysphagia. 

For  local  applications:  Argentide,  1  to  200;  argyrol,  \Q%  ; 
iodine,  potassium  iodide  and  glycerine;  heroin  powder  applied  dry 
to  ulcerations;  orthoform  powder  applied  dry. 

Montefiore  Home  Country  Sanitarium,  Bedford  Hills,  N.  Y. 

In  the  routine  treatment  of  laryngeal  tuberculosis  at  the  Monte- 
fiore Home  Country  Sanitarium  orthoform  emulsion  is  used,  made 
up  as  follows :  Menthol,  2-5  grams ;  oil  of  sweet  almonds,  30  grams ; 
yolk  of  one  egg;  orthoform,  12.5  grams;  water  added  to  make  100 
grams. 

In  addition,  silver  salts  are  used  in  various  strengths;  also 
lactic  acid  in  various  strengths.  These  two  agents  are  applied  by 
means  of  applicators,  whereas  the  emulsion  is  injected  by  a  laryn- 
geal syringe.  The  laryngeal  medicator  of  Dr.  Yankauer,  made 
by  Tiemann,  is  also  employed.  By  means  of  this  little  apparatus 
a  patient  may  medicate  his  own  larynx,  using  the  emulsion  men- 
tioned or  any  other  agent  (such  as  formalin)  which  may  be  desired. 
Eudowood  Sanatorium,  Towson,  Md. 

At  the  Eudowood  Sanatorium,  Towson,  Maryland,  the  following 
procedure  is  used  in  the  treatment  of  tuberculous  ulcers  of  the 
larynx: 

Topical  applications  of  lactic  acid,  15  to  50%,  followed  by  a 
spray  composed  of  20  grains  of  menthol  to  1  ounce  of  liquid  alboline. 

A  spray  of  2%  cocaine  is  used  as  often  as  is  necessary  to 
relieve  the  pain. 

Insufflation  of  orthoform  powder,  or  the  patient  is  directed  to 
slowly  dissolve  an  orthoform  lozenge  in  his  mouth. 

41 


These  treatments  are  enhanced  by  the  application  of  an  ice 
bag  to  the  throat,  enforced  rest  of  the  vocal  cords  and  rectal 
feeding,  if  necessary. 

In  laryngeal  complications,  semi-solid  diet  is  generally  more 
easily  swallowed.    This  is  facilitated  by  a  reclining  position.    Cold 
compresses  give  some  relief. 
Chicago  Fresh  Air  Hospital 

For  the  relief  of  pains  and  difficulty  in  swallowing,  the  nurse  is 
instructed  to  spray  the  larynx  with  a  3  per  cent  solution  of  cocaine 
before  each  meal. 

As  a  more  efficient  treatment,  but  slower  in  action,  the  administra- 
tion of  anaesthesine  to  the  ulcerated  epiglottis  with  a  powder  blower 
is  recommended.  This  is  usually  done  by  the  physician,  as  is,  also,  the 
insufflation  of  iodoform. 

Cold  packs  are  also  used  to  give  temporary  relief,  but  they  are 
not  recommended  as  being  very  reliable. 

Authorities  differ  regarding  the  proper  diet  for  the  advanced 
consumptive.  It  is  generally  conceded,  however,  that  it  should  not 
vary  to  any  great  extent  from  the  ordinary  liberal  diet,  unless 
intestinal  or  other  complications  arise.  The  physical  idiosyncrasy 
of  each  patient  must  first  of  all  be  taken  into  consideration,  and 
this  is  primarily  a  matter  to  be  decided  upon  by  the  physician  in 
charge.  The  nurse  should,  however,  be  resourceful  in  h«r  sugges- 
tions as  to  preparing  a  variety  of  palatable  dishes.  According  to 
Walters  ("The  Open  Air  Treatment"),  in  intestinal  tuberculosis, 
such  foods  as  oatmeal,  green  vegetables,  fruit  and  various  casein 
preparations  are  better  dispensed  with,  as  they  are  likely  to  cause 
irritation  and  diarrhoea.  Meat  and  meat  juices  should  also  be 
given  with  caution,  as  they,  too,  cause  diarrhoea. 

In  hemorrhage,  a  cold  diet  should  be  given,  such  as  milk,  eggs, 
gelatin  and  custard.  The  nurse  must  insist  in  absolute  rest  and  the 
patient  should  not  be  permitted  to  move  until  the  danger  of  bleeding 
is  over.  Nervousness  always  accompanies  hemorrhage,  and  the 
nurse  can  do  much  to  allay  this  by  assuring  the  patient  that  few 
people  die  from  hemorrhage. 

In  closing,  it  might  be  well  to  mention  some  points  relative 
to  the  nurse's  equipment,  her  mode  of  dressing,  etc.  Her  dress 
should  be  simply  made  and  washable.  Aprons  made  of  soft  cotton 
crepe  are  recommended  because  of  the  small  space  they  occupy 
in  the  bag. 

The  contents  of  the  bag,  which  should  be  lined  with  washable, 
removable  lining,  should  include:  Alcohol,  tr.  iodine,  green  soap, 

42 


olive  oil,  boric  acid  powder,  boric  acid  crystals,  vaseline,  cold  cream, 
mouth  wash,  tongue  depressors,  adhesive  plaster  (3"  wide),  ban- 
dages, safety  pins  (small  and  large),  applicators,  scrub  brush,  face 
shields,  probe,  scissors  (2  pair),  forceps,  thermometers  (3),  medi- 
cine dropper,  bags  of  dressings,  dressing  towels,  hand  towels  (2), 
apron. 

Because  tuberculosis  is  so  lasting  and  makes  a  family,  ordin- 
narily  self-supporting,  frequently  dependent,  it  will  be  absolutely 
necessary  for  the  nurses  to  have  access  to  a  loan  closet.  This  closet 
should  contain  the  following  articles:  Sheets  and  pillow  slips,  bed 
pan,  blankets,  rubber  rings,  gowns  or  pajamas,  rubber  sheets, 
tooth  brushes,  cold  cream,  rubber  gloves,  glass  syringes,  pus  basins, 
enema  bags,  connecting  tubes,  rectal  tubes,  nurses'  hand  towels, 
surgical  towels,  instrument  cases,  aprons  and  gown,  loan  book. 


Up  to  the  present  time  the  field  nurses  of  the  Dispensary 
Department  of  the  Chicago  Municipal  Tuberculosis  Sanitarium  have 
taken  care  chiefly  of  ambulant  cases,  the  total  number  of  cases 
under  observation  in  1913  being  12,  397,  with  39,737  visits  by  nurses 
to  positive  and  suspected  cases  in  their  homes.  Lately  (September 
1914)  the  nursing  force  of  the  Dispensary  Department  has  been  in- 
creased to  fifty  nurses  to  take  care  of  all  tuberculosis  cases  in  their 
homes,  including  advanced  cases  and  those  of  surgical  tuberculosis. 


43 


OPEN  AIR  SCHOOLS  IN  THIS  COUNTRY 
AND  ABROAD 

By  FRANCES  M.  HEINRICH,  R.  N. 

Head  Nurse,  Post  Graduate  Dispensary  of  the  Chicago  Municipal 
Tuberculosis  Sanitarium. 


In  every  community  where  the  tuberculosis  problem  has  been 
seriously  taken  in  hand  the  importance  of  the  presence  of  the  infec- 
tion in  children  had  to  be  considered  and  this  has  been  carefully 
studied  by  those  who  realize  that  tuberculosis,  far  from  being  a 
disease  chiefly  of  adult  life,  is  intimately  associated  with  childhood. 
Therefore,  is  it  not  most  important  that  all  children,  who  have 
either  been  exposed  to  tuberculosis  through  the  presence  of  an 
active  case  in  their  home,  or  show  a  family  predisposition  to  the 
disease,  should  be  given  special  consideration,  and  every  opportu- 
nity furnished  to  make  it  possible  for  them  to  withstand  the  latent 
infection  or  to  overcome  the  inherited  lack  of  resistance?  The 
best  means  of  meeting  this  important  problem,  as  far  as  school 
children  are  concerned,  is  through  the  medium  of  Open  Air 
Schools,  not  only  because  of  the  benefit  to  the  individual  case,  but 
also  because  of  the  very  important  educational  influence  on  the 
community  at  large. 

The  first  Open  Air  School  was  opened  in  Charlottenburg,  Ger- 
many, a  suburb  of  Berlin,  in  the  year  1904,  a  school  of  a  new  type, 
to  which  the  Germans  gave  the  name  Open  Air  Recovery  School. 
The  object  was  to  create  a  school  where  children  could  be  taught 
and  cured  at  the  same  time,  and  this  same  purpose  has  obtained 
in  all  other  schools  of  similar  type  which  have  since  been  opened. 
This  new  educational  venture  was  designed  for  backward  and 
physically  debilitated  pupils  who  could  not  keep  up  with  the  work 
in  the  regular  schools  and  who  were  not  so  mentally  deficient  that 
they  were  fit  subjects  for  the  classes  of  mentally  subnormal  chil- 
dren. It  was  felt  that  if  these  children  were  sent  to  sanatoria 
they  would  undoubtedly  improve  physically,  but  would  fall  back  in 
the  class  work;  while,  on  the  other  hand,  if  they  remained  in  the 
regular  school  they  would  deteriorate  physically.  It  was  to  meet 

44 


theso  needs,  then,  that  this  new  type  of  school  was  devised.  As 
the  name  implies,  the  school  was  held  almost  entirely  in  the  open 
air,  the  regime  consisting  of  outdoor  life,  plenty  of  good  food, 
strict  hygiene,  suitable  clothing,  and  school  work  so  modified  as 
to  suit  the  conditions  of  the  children. 

During  its  first  year  the  Charlottenburg  School  was  open  for 
only  three  months,  but  upon  publication  of  the  first  report  of  the 
results  accomplished  it  was  decided  to  keep  the  school  open  a 
longer  period.  The  desire  to  open  other  schools  of  similar  type 
spread  rapidly  throughout  Germany,  as  well  as  the  rest  of  Europe 
and  other  parts  of  the  world. 

Probably  the  best  argument  for  maintaining  such  schools  was 
not  only  the  physical  benefit  derived,  but  the  actual  advance  made 
by  the  children  in  their  studies,  although  they  spent  less  than  half 
as  much  time  on  school  work  as  did  their  companions  in  tne 
regular  schools,  not  only  fully  maintaining  their  standing,  but  ever 
surpassing  their  companions  in  the  regular  classes.  Through  re- 
sults obtained  from  this  first  experiment  in  Charlottenburg  came 
the  resolve  on  the  part  of  school  authorities  of  other  cities  to  in- 
augurate Open  Air  Schools  in  their  respective  localities,  and  in  less 
than  three  years  the  movement  had  spread  to  England,  where,  in 

1907,  London  opened  her  first  school,  modeled  after  that  of  Char- 
lottenburg. 

The  same  remarkable  results  obtained  during  the  first  season 
here,  as  in  the  three  years  previously  reported  from  Charlottenburg, 
awakened  such  popular  enthusiasm  that  towns  and  cities  in  dif- 
ferent parts  of  England  began  to  plan  for  similar  schools  in  the 
communities  most  needing  them. 

Meanwhile,  the  movement  spread  to  the  United  States.     In 

1908,  one  year  after  England  had  established  her  first  Open  Air 
School,  this  country  opened  its  first  Open  Air  School  in  Providence, 
Rhode  Island.    Although  Providence  has  the  distinction  of  priority 
in  this  matter,  the  school  inaugurated  by  Providence  was  not, 
strictly  speaking,  the  first  Open  Air  School  established  on  American 
territory,  as  a  school  of  this  type  was  opened  in  1904  in  San  Juan, 
Porto  Rico,  by  L.  P.  Ayres,  now  Associate  Director  of  the  Depart- 
ment   of    Hygiene    of    the    Russell    Sage    Foundation,    at    that 
time  Superintendent  of  Schools  for  Porto  Rico.     The  San  Juan 
school  was  an  experiment.    It  was  built  to  accommodate  100  chil- 
dren.   It  was  simple  in  its  arrangements;  it  had  a  floor  and  roof 
but  no  sides.    Venetian  blinds  were  provided  to  keep  out  rain  and 
the  too  direct  sunlight.    The  school  was  designed  for  children  of 
no  particular  class,  but  was  established  in  the  endeavor  to  demon- 

45 


strate  that  the  regime  which  has  proven  beneficial  for  weak  and 
ailing  children  will  also  benefit  those  that  are  strong  and  seemingly 
healthy.  The  results  demonstrated  fully  the  correctness  of  this 
idea.  The  children  greatly  preferred  the  outdoor  classes,  and  even 
the  teachers  were  most  anxious  to  be  assigned  to  outdoor  work. 
Since  then  at  least  one  more  school  of  similar  type  has  been  opened 
in  Porto  Rico. 

Before  showing  what  the  United  States  has  done  in  this  very 
important  movement,  it  might  be  interesting  to  learn  how  Ger- 
many and  England  have  further  developed  their  program,  as  the 
work  done  in  these  countries,  particularly  in  Germany,  served  as 
the  basis  of  the  Open  Air  School  movement  in  this  country  in  the 
initial  stages  of  its  development. 

For  the  past  fifteen  years  Germany  has  carried  on  medical 
inspection  of  schools  in  a  very  thorough  and  efficient  manner.  This 
has  drawn  special  attention  to  backward  children.  These  children 
are  treated  there  in  special  classes  and  sometimes  in  special  schools. 
The  quantity  of  instruction  given  them  is  reduced  and  every  en- 
deavor is  made  to  increase  its  effectiveness.  The  classes  are  taught 
by  capable  teachers  and  the  children  have  the  benefit  of  suitable 
dietary,  bathing  and  other  hygienic  provisions. 

In  Charlottenburg,  in  1904,  there  were  a  large  number  of  back- 
ward children  who  were  about  to  be  removed  from  the  ordinary 
elementary  schools  to  special  classes.  When  examined,  it  was 
found  that  many  of  them  were  in  a  debilitated  condition  owing  to 
anaemia,  or  various  other  ailments  in  an  incipient  stage.  This  cir- 
cumstance afforded  an  ideal  opportunity  for  the  co-operation  of 
the  teacher  and  the  school  physician  in  devising  and  operating,  for 
such  children,  an  Open  Air  School.  The  general  school  regime 
was  modified  to  meet  the  educational  and  physical  needs  of  these 
children,  the  treatment  consisting,  as  above  stated,  of  abundance 
of  fresh  air,  pleasant  and  hygienic  surroundings,  careful  super- 
vision, wholesome  food  and  judicious  exercise.  The  ordinary  school 
work  was  modified  to  meet  the  individual  condition  of  children; 
the  hours  of  teaching  were  cut  in  two  and  the  classes  so  reduced 
that  no  teacher  had  more  than  twenty-five  pupils  under  her  care. 
The  site  chosen  for  the  first  school  in  Charlottenburg  was  a  large 
pine  forest  on  the  outskirts  of  the  town.  The  sum  of  $8,000 
was  granted  by  the  municipality  for  carrying  out  the  plan,  and 
inexpensive  but  suitable  wooden  buildings  were  erected.  At  first 
ninety-five  children  were  admitted  to  the  school,  but  later  the 
number  was  increased  to  120,  and  still  later  to  250.  These  children 
were  mainly  anaemic  or  suffering  from  slight  pulmonary,  heart  or 

46 


scrofulous  conditions.  Those  suffering  from  acute  or  communi- 
cable diseases  were  rigidly  excluded.  Of  the  five  buildings  erected, 
three  were  plain  sheds  about  81  feet  long  and  18  feet  wide,  one  of 
them  being  completely  open  on  the  south  side  and  closed  on  the 
other  sides,  of  sufficient  size  to  shelter  during  rainy  weather  about 
200  children.  The  other  two  sheds  contained  five  classrooms  and 
a  teachers'  room.  These  were  closed  in  on  all  sides,  provided  with 
heating  arrangements,  and  used  for  classrooms  during  very  cold 
or  unpleasant  weather,  only  one  of  the  buildings  was  fitted 
with  tables  and  benches  intended  for  meals,  or  for  work  in  in- 
clement weather.  This  building  was  open  on  all  sides.  All  over  the 
school  grounds,  which  were  fenced  in,  there  were  small  sheds  open 
on  all  sides,  fitted  with  tables  and  benches  to  accommodate  from 
four  to  six  children.  These  served  as  shelters.  There  were  small 
buildings  for  shower  baths,  kitchen  and  a  separate  shed  where  the 
wraps  of  the  boys  and  girls  were  kept.  In  these  were  individual 
lockers  which  contained  numbered  blankets  for  protection  against 
cold,  and  waterproofs  against  rain. 

The  children  in  this  school  report  at  a  little  before  8  a.  m.  and 
leave  at  a  quarter  of  7  p.  m.  For  breakfast  they  are  given  a  bowl  of 
soup  and  a  slice  of  bread  and  butter.  Classes  commence  at  8  o'clock 
and  continue  with  an  interval  of  five-minutes'  rest  after  each  half 
hour.  At  10  a.  m.  the  children  receive  one  or  two  glasses  of  milk 
and  a  slice  of  bread  and  butter.  After  this  they  play,  perform 
gymnastic  exercises,  do  manual  work  or  read.  Dinner  is  served  at 
12 :30  p.  m.  and  consists  of  about  three  ounces  of  meat,  with  vege- 
tables and  soup.  After  dinner  the  children  rest  or  sleep  for  two 
hours  on  folding  chairs.  At  3  p.  m.  comes  more  class  work  and  at  4 
p.  m.  milk,  rye  bread  and  jam  is  given.  The  rest  of  the  afternoon  is 
given  over  to  informal  instruction  and  play.  The  last  meal  consists  of 
soup,  bread  and  butter,  after  which  the  children  are  dismissed. 
Some  walk  home;  some  use  street  cars.  In  case  of  the  very  poor 
children  the  city  pays  the  fare,  while  the  transportation  is  furnished 
for  others  through  the  generosity  of  the  street  car  company.  The 
e'xpense  of  the  feeding  is  borne  by  the  municipality,  in  the  case  of 
those  who  can  not  pay,  and,  for  the  others,  is  defrayed  in  part  or 
whole  by  the  parents. 

The  work  of  the  school  physician  consists  of  careful  examina- 
tion, treatment  and  supervision  of  these  children.  Attention  is 
principally  directed  to  heart,  lungs  and  general  condition  with 
respect  to  color,  muscular  and  flesh  development.  Weight  and 
measurements  are  taken  every  two  weeks,  and  at  the  end  of  the 
school  period  the  children  are  very  carefully  examined  and  condition 
compared  with  that  noted  upon  their  admission. 

47 


The  regime  covers  such  important  phases  of  hygiene  as  suit- 
able clothing,  attention  to  daily  habits,  bathing,  giving  of  warm 
baths  for  those  who  are  anaemic  and  nervous,  and  of  mineral  baths 
for  those  who  are  scrofulous.  Bathing  plays  a  very  important  part. 
All  of  the  children  receive  two  or  three  warm  shower  baths  a  week. 
A  trained  nurse  is  in  attendance. 

The  educational,  physical  and  moral  results  obtained  are  re- 
markable. There  is  a  great  improvement  in  their  behavior,  espe- 
cially with  regard  to  order,  cleanliness,  self-help,  punctuality  and 
good  temper.  This  is  undoubtedly  due  to  their  removal,  during 
practically  all  of  their  waking  hours,  from  the  influences  of  the 
street  life  to  the  more  wholesome  influences  of  the  school.  The 
children  are  taught  to  regard  themselves  as  members  of  a  large 
family,  are  trained  to  assist  in  the  daily  work  and  are  taught  to 
be  helpful  and  considerate  of  each  other. 

This,  in  detail,  is  the  regime  of  the  first  Open  Air  School  con- 
ducted in  Germany. 

The  number  of  Open  Air  Schools  at  present  in  Germany  is  at 
least  ten,  with  an  attendance  of  approximately  1,500. 


In  England  the  Open  Air  Schools  were  made  possible  through 
the  work  of  the  local  educational  authorities  and  co-operation  of 
dispensaries  for  treatment  and  care  of  tuberculous  children. 

As  in  other  countries,  general  legislation  for  the  control  of 
tuberculosis  has  had  considerable  bearing  on  the  Open  Air  School 
situation  in  England.  Among  the  legislative  acts  should  be  men- 
tioned : 

(a)  The  Act  of  1911  providing  building  grants  for  the 
establishment  of  sanatoria,  dispensaries  and  other  auxil- 
iary institutions. 

(b)  Compulsory  notification  of  tuberculosis,  etc. 
Notification  of  tuberculosis,  for  instance,  besides  bringing  to 

notice  of  the  school  medical  officer  cases  of  tuberculosis  which 
might  otherwise  not  come  before  him  until  a  late  period,  serves  in 
many  cases  to  keep  him  informed  as  to  "contact  cases" — cases  of 
children  in  contact  with  communicable  tuberculosis. 

At  Burton-on-Trent  a  system  was  instituted  for  periodical 
examination  of  school  children  who  are  either  members  of  a  family 
in  which  there  is  or  has  been  a  case  of  pulmonary  tuberculosis,  or 
who  are  attending  school  while  residing  in  houses  in  which  there 
is  an  existing  case  of  this  disease.  All  notified  cases  of  tuberculosis 
are  visited  by  the  Assistant  Medical  Officer  of  Health,  who  is  also 
Assistant  School  Medical  Officer,  and  the  names  of  any  children 

48 


living  in  the  house,  or  related  to  the  case,  are  ascertained,  together 
with  the  school  they  are  attending.  These  names  are  entered  in  a 
special  register  and  when  the  pupils  of  a  school,  at  which  any  of 
these  children  are  attending,  are  examined,  a  special  examination  is 
made  of  the  latter.  This  examination  is  repeated  two  or  three  times 
a  year. 

In  another  part  of  England  a  special  letter  is  sent  to  the 
occupants  of  all  houses  from  which  the  disease  has  been  notified, 
calling  attention  to  the  special  importance  of  early  detection  of 
tuberculosis  in  children,  and  asking  that  the  children  should  be 
brought  to  the  school  clinic  for  examination. 

In  Lancashire  the  Medical  Inspector  calls  on  the  Medical  Officer 
of  Health  and  obtains  a  list  of  names  of  persons  suffering  from 
tuberculosis,  so  that  the  children,  if  of  school  age,  may  be  examined. 

At  Newcastle-on-Tyne  all  children  exposed  at  any  time  to 
infection  are  kept  under  observation  and  re-examined.  The  re- 
examination  continues  even  after  fatal  termination  of  the  tuber- 
culosis case  with  which  the  child  was  in  contact. 

Under  the  Finance  Act  of  1911  a  sum  of  about  $500,000  was 
especially  appropriated  for  providing  what  are  known  as  "Sana- 
torium Schools"  for  children  suffering  from  pulmonary  or  surgical 
tuberculosis.  These  schools  are  known  as  the  Residential  Open  Air 
Schools  of  Recovery,  and  the  need  of  such  schools  for  children 
requiring  more  continuous  care  than  is  provided  at  a  day  Open  Air 
School  is  becoming  widely  recognized.  Many  children  of  the  type 
already  mentioned  can  not  be  satisfactorily  treated  unless  they  can 
be  taken  completely  away,  for  a  time,  from  their  home  environment. 
Such  treatment  as  is  needed  for  many  of  these  children  is  not  and 
can  not  be  offered  in  the  ordinary  hospital  and  certainly  not  at 
their  homes. 

The  designs  and  arrangements  of  the  Residential  Open  Air 
School  of  Recovery  are  very  attractive.  They  are  well  equipped 
to  fulfill  their  function.  The  children,  received  between  the  ages  of 
seven  and  twelve  years,  are  those  suffering  from  anaemia,  debility, 
or  slight  heart  lesions.  Cases  of  active  tuberculosis  are  barred.  No 
child  is  received  for  a  shorter  period  than  three  months,  and  this 
period  may  be  prolonged  on  the  recommendation  of  the  Medical 
Officer. 

The  children  rise  at  7  a.  m.  and  retire  at  6:30  p.  m.  Those 
who  are  able,  make  their  own  beds  and  do  some  of  the  domestic 
work.  The  diet  is  liberal,  with  abundance  of  milk  and  eggs.  Care- 
ful attention  is  given  to  inculcating  habits  of  personal  and  general 
hygiene.  All  children  receive  a  daily  bath.  Careful  attention  is 

49 


paid  to  the  teeth,  tonsils  and  adenoids.  All  these  conditions  must 
be  attended  to  before  admission.  Beyond  this,  very  little  treatment 
is  given.  Children  are  weighed  once  in  two  weeks.  Instruction 
is  chiefly  practical.  Instruction  in  gardening  is  given  twice  a  week 
and  other  occupations  taught  are  raffia  work,  plasticine  modeling, 
cardboard  modeling,  brush  work  and  needle  work. 

The  number  of  Open  Air  Schools  at  present  in  England  is  at 
least  thirty-five,  with  an  attendance  of  at  least  2,500.  Forty-two 
other  cities  are  listed  as  carrying  on  some  form  of  open  air  edu- 
cation. 


In  the  United  States  the  Open  Air  School  movement,  from 
its  inception,  has  been  closely  connected  with  the  general  anti- 
tuberculosis  movement. 

The  credit  of  establishing  the  first  Open  Air  School  in  America 
belongs,  as  previously  stated,  to  Providence,  Rhode  Island,  where 
the  work  was  begun  in  January,  1908.  The  school  was  opened 
in  a  brick  school  house  in  the  center  of  the  city.  A  room  on  the 
second  floor  was  chosen  and  remodeled  by  removing  part  of  the 
south  wall.  For  the  wall  thus  removed  windows  were  substituted. 
These  extended  from  near  the  floor  to  the  ceiling,  with  hinges  at 
the  top  and  with  pulleys  so  arranged  that  the  lower  ends  could  be 
raised  to  the  ceiling.  The  desks  were  placed  in  front  of  the  open 
windows  in  such  a  manner  that  the  children  received  the  fresh  air 
at  their  backs  and  the  light  over  their  shoulders.  Suitable  clothing 
was  provided  for  cold  weather  and,  in  case  of  necessity,  soapstone 
foot  warmers  were  used. 

The  school  was  started  as  an  ungraded  school  and  ten  pupils 
were  enrolled  at  the  time  of  its  opening,  the  number  later  increasing 
to  twenty-five.  Practically  all  children  were  selected  by  the  visiting 
nurse  of  the  local  League  for  the  Suppression  of  Tuberculosis  from 
infected  homes  under  her  supervision.  In  a  few  instances  children 
with  moderately  advanced  lesions  were  admitted. 

The  children  reported  at  9  a.  m.  and  a  recess  was  given  at 
10 :30,  when  they  were  served  soup.  At  noon  they  had  a  light  lunch 
of  pudding  served  with  cream,  hot  chocolate  or  cocoa  made  entirely 
with  milk.  Some  of  the  children  brought  additional  food  from  home. 
All  of  the  cooking  was  done  by  the  teacher.  Careful  attention  to 
is  given.  Children  are  weighed  once  in  two  weeks.  Instruction 
is  chiefly  practical.  Instruction  in  gardening  is  given  twice  a  week 
general  cleanliness  and  hygiene  of  the  teeth  was  insisted  upon. 
Individual  drinking  cups  and  tooth  brushes  were  provided.  The 
children  took  turns  in  washing  dishes,  setting  the  table  and  helping 

50 


to  serve.  Children  were  dismissed  at  2 : 30  p.  m.  They  were  provided 
with  car  tickets  by  the  League  for  the  Suppression  of  Tuberculosis, 
some  for  traveling  both  ways,  some  for  one  way  only,  depending 
upon  the  means  of  the  family.  During  school  session  light  gym- 
nastic exercises  were  given  and  proper  methods  of  breathing  taught. 
In  the  spring  they  had  a  garden  to  work  in. 

The  Providence  school  is  at  present  a  part  of  the  general  school 
system.  The  school  supplies  and  teacher's  salary  are  furnished 
by  the  Board  of  Education.  Food  and  carfare  are  supplied  by  the 
League  for  the  Suppression  of  Tuberculosis.  A  physician  is  dele- 
gated by  the  League  and  one  of  the  regular  Medical  Inspectors  of 
the  city  schools  works  in  co-operation  with  him. 

Providence  has  at  present  two  schools,  with  an  attendance  of 
forty.  One  more  Open  Air  School  and  two  roof  classes  may  be 
provided  by  the  Board  of  Education  in  1914.  In  addition,  the 
Providence  League  for  the  Suppression  of  Tuberculosis  conducts 
a  Preventorium  for  thirty  children  at  the  Lakeside  Preventorium, 
Rhode  Island. 


Boston  started  its  first  Open  Air  School  in  July,  1908. 
The  work  was  carried  on  by  the  Boston  Association  for  the  Relief 
and  Control  of  Tuberculosis.  The  school  was  located  at  Parker 
Hill,  Roxbury.  The  same  regime  was  followed  as  in  previously 
reported  schools.  No  formal  instruction,  however,  was  attempted 
at  first.  The  school  was  simply  a  day  camp.  The  benefit  derived 
by  the  children  in  the  first  open  air  camp  for  children  led  the 
Association  to  ask  the  Boston  School  Board  to  co-operate  with 
them  in  converting  the  camp  into  an  outdoor  school.  This  was 
agreed  to,  the  School  Board  supplying  teacher,  desks,  books, 
etc.,  the  Association  furnishing  the  necessary  clothing,  food,  a 
nurse,  attendants,  home  instruction  and  medical  services.  The  same 
schedule  was  followed  here  as  in  the  other  Open  Air  Schools.  Gen- 
eral and  personal  hygiene  was  insisted  upon.  The  school  was  kept 
open  Saturdays  and  during  the  holidays.  The  children  who  were 
able  paid  ten  cents  a  day  to  help  defray  the  cost  of  food.  In  case 
they  could  not  afford  this,  the  money  was  supplied  by  some  charity 
organization.  While  the  combined  public  and  private  support  had 
proved  satisfactory,  it  seemed  best,  for  many  reasons,  to  reorganize 
the  school  so  that  it  would  be  entirely  under  municipal  authority, 
and  this  has  since  been  done.  At  the  present  time  the  school  is 
maintained  by  the  Boston  Consumptives'  Hospital  and  the  Boston 
School  Board.  The  hospital  furnishes  transportation,  food,  etc., 
while  the  School  Board  gives  school  supplies,  books,  desks,  etc., 

51 


and  pays  the  salaries  of  the  teachers.  The  children  are  selected 
by  the  school  physicians,  the  type  considered  being  the  anaemic, 
poorly  nourished,  those  with  enlarged  glands,  or  convalescents. 
Cases  of  active  tuberculosis  are  not  admitted. 

Boston  has  at  present  fifteen  Open  Air  Schools,  with  a  total 
enrollment  of  about  500  children. 


The  first  school  established  in  New  York  City  was  started 
under  the  auspices  of  the  Department  of  Education  and  was  located 
on  the  ferryboat  Southfield,  which  was  maintained  as  an  outdoor 
camp  for  tuberculous  patients  by  Bellevue  Hospital.  It  was 
through  the  special  desire  of  the  children  who  were  patients  at 
the  camp  that  the  school  was  started,  for  they  banded  together 
one  day  and  informed  the  doctor  that  they  wanted  to  have  a  teacher 
and  attend  school.  When  their  action  was  reported  to  the  Board  of 
Education  it  was  felt  that  such  an  unusual  plea  should  be  given  a 
favorable  response,  and  in  December,  1908,  the  school  on  the  ferry- 
boat was  made  an  annex  of  Public  School  No.  14. 

This  school,  except  for  its  location,  does  not  differ  from  other 
schools  of  similar  type.  The  Board  of  Education  pays  the  teacher 
and  furnishes  the  school  supplies.  Food  and  clothing  are  supplied 
by  the  hospital.  The  school  is  an  ungraded  one  and  the  number 
of  children  taught  by  one  teacher  averages  thirty. 

Four  more  Open  Air  Schools  have  since  been  established,  three 
on  ferryboats  and  one  on  the  roof  of  the  Vanderbilt  Clinic  at  West 
Sixtieth  street.  Officially,  all  these  schools  are  considered  to  be 
annexes  of  the  regular  public  schools. 

In  October,  1909,  $6,500  was  granted  to  the  Board  of 
Education  by  the  Board  of  Estimate  and  Apportionment  for  the 
purpose  of  remodeling  rooms  in  some  of  the  public  schools  for  use 
as  Open  Air  Rooms.  A  special  conference  was  held  in  December 
of  that  year  by  medical  and  school  authorities  to  decide  how  best 
to  remodel,  furnish  and  equip  these  new  rooms  for  this  purpose; 
also  how  the  children  should  be  chosen  for  these  classes. 

It  was  decided  that  the  maximum  number  of  children  admitted 
to  any  one  open  air  classroom  should  not  exceed  twenty-five,  the 
children  to  be  chosen  by  the  director  of  the  tuberculosis  clinic 
nearest  the  school  and  the  school  principal.  No  child  was  to 
be  assigned  to  the  room  until  the  parents'  permission  had  been 
secured  in  writing.  Children  moving  from  one  district  to  another 
were  to  be  followed  up  and  cared  for  in  the  new  district.  No 
special  rule  was  adopted  defining  the  physical  condition  entitling 
the  child  to  admission.  Each  case  was  to  be  considered  indi- 

52 


virtually,  and  the  only  definite  rule  was  that  no  open  case  of  tuber- 
culosis should  be  admitted.  The  minimum  temperature  of  the  room 
was  50  degrees  F.  The  rooms,  wherever  possible,  were  to  be  located 
on  the  third  floor.  The  first  of  these  open  air  classes  was  established 
in  April,  1910.  Such  popular  interest  was  awakened  by  the  in- 
auguration of  these  classes  that,  as  a  direct  result,  a  special  privi- 
lege was  granted  by  the  Commissioners  of  Central  Park  permitting 
children  of  the  kindergarten  classes  of  the  public  schools  to  pursue 
their  studies  in  the  open  air  in  Central  Park. 

At  present  New  York  has  thirty-three  Open  Air  Schools  and 
Open  Window  Rooms,  with  a  total  enrollment  of  at  least  1,000. 


Chicago's  first  Outdoor  School  for  Tuberculous  Children  was 
inaugurated  as  a  result  of  the  joint  co-operation  of  the  Chicago 
Tuberculosis  Institute  and  the  Board  of  Education.  This  school 
was  opened  during  the  first  week  of  August,  1909,  on  the  grounds 
of  the  Harvard  School  at  Seventy-fifth  street  and  Vincennes  Road. 
The  Board  of  Education  assigned  a  teacher  to  the  school  and  fur- 
nished the  equipment,  while  the  Tuberculosis  Institute  supplied  the 
medical  and  nursing  service,  selected  the  children  and  provided  the 
food. 

Except  during  inclement  weather,  the  children  occupied  a  large 
shelter  tent  in  which  thirty  reclining  chairs  were  placed.  Meals 
were  served  in  the  basement  of  the  school  building,  where  a  gas 
range,  cooking  utensils  and  tables  were  installed  for  this  special 
purpose. 

The  nurse,  who  was  assigned  by  the  Tuberculosis  Institute  on 
half-time  attendance,  visited  the  school  each  afternoon,  took  daily 
afternoon  temperatures,  pulse  and  respiration,  looked  after  the 
general  physical  condition  of  the  children,  made  weekly  records 
of  their  gain  or  loss  in  weight  and  did  instructive  work  in  the 
home  of  each  pupil. 

Of  the  thirty  children  selected,  seventeen  had  pulmonary  tuber- 
culosis, two  had  tubercular  glands,  and  eleven  were  designated  as 
"pre-tuberculous."  None  of  the  children  had  passed  to  the  "open" 
or  infectious  stage.  On  admission  two-thirds  of  the  children  showed 
a  temperature  of  from  99  to  100.2  degrees. 

The  daily  program  was  similar  to  that  already  described  for 
the  Providence  and  Boston  Schools.  The  school  was  kept  open  for 
a  period  of  only  one  month,  with  excellent  results.  During  this  time 
the  thirty  children  made  a  net  gain  of  115  pounds  in  weight,  and 
at  the  close  of  the  period  practically  all  of  them  showed  a  normal 
temperature,  with  their  general  condition  greatly  improved. 

53 


It  is  needless  to  say  that  the  experiment  created  a  great  deal 
of  local  interest  in  the  problem  of  better  school  ventilation.  Those 
who  had  the  success  of  the  movement  most  intimately  at  heart 
realized,  however,  that  the  undertaking  lacked  the  element  of  per- 
manency and  that  the  results  accomplished  by  it  lacked  that  degree 
of  conclusiveness  which  would  attend  the  same  results  if  secured 
through  the  operation  of  an  all-the-year-round  school. 

The  opportunity  to  demonstrate  the  effectiveness  of  such  an 
all-the-year-round  school  was  realized  in  the  Fall  of  1909  by  a 
grant  from  the  Elizabeth  McCormick  Memorial  Fund  to  the  United 
Charities  for  the  purpose  of  conducting  such  a  school  on  the  roof 
of  the  Mary  Crane  Nursery  at  Hull  House.  This  school  was  opened 
by  the  United  Charities  in  October  with  twenty-five  carefully 
selected  children,  and  was  conducted  throughout  the  following 
winter  and  spring  with  the  co-operation  of  the  Board  of  Education 
and  the  Chicago  Tuberculosis  Institute.  During  the  same  winter 
the  Public  School  Extension  Committee  of  the  Chicago  Women's 
Club,  co-operating  with  the  Board  of  Education,  established  two 
classes  for  anaemic  children  in  open  window  rooms — one  in  the 
Moseley  and  one  in  the  Hamline  School.  Here  the  regular  regime 
was  broken  by  a  rest  period,  and  lunches  of  bread  and  milk  were 
served  twice  each  day.  "Fresh  Air  Rooms,"  in  which  the  windows 
were  thrown  wide  open  and  the  heat  cut  off,  were  also  established 
for  normal  children  in  several  rooms  in  the  Graham  School.  No 
attempt  was  made  here  to  furnish  lunches  and  no  rest  period  was 
provided. 

There  were,  then,  during  the  school  year  of  1909  and  1910, 
three  distinct  classes  of  children  cared  for  by  three  distinct  agen- 
cies— the  classes  for  normal  children  in  the  low  temperature  rooms 
at  the  Graham  School;  anaemic  children,  with  rest  period  and  two 
lunches,  in  the  Moseley  and  Hamline  Open  Window  Rooms,  and 
the  Roof  School  for  Tuberculous  Children,  with  specially  provided 
clothing,  sleeping  outfits,  three  meals  a  day  and  medical  and  nursing 
attendance,  at  the  Mary  Crane  Nursery. 

The  same  condition  existed  throughout  the  following  year — 
1910-11 — with  the  addition  of  one  Open  Air  School  on  the  roof  of 
the  municipal  bath  building  on  Gault  Court,  given  rent  free  by  the 
City  Health  Department,  and  two  Open  Window  Rooms  for  anaemic 
children  in  the  Franklin  School,  all  maintained  by  the  Elizabeth 
McCormick  Memorial  Fund. 

In  1911  the  Elizabeth  McCormick  Memorial  Fund  assumed  the 
responsibility  for  all  the  open  air  school  work  carried  on  in  the 

54 


Chicago  Public  Schools,  and  began  the  standardization  of  methods 
which  should  be  employed  in  the  conduct  of  such  schools. 

Through  the  initiative  of  the  Elizabeth  McCormick  Memorial 
Fund  the  Chicago  Open  Air  School  work  has  been  rapidly  developed 
during  1912  and  1913,  the  program  being  along  the  line  of  addi- 
tional roof  schools  for  tuberculous  children  and  an  increasing  num- 
ber of  open  window  rooms  for  anaemic  children  and  children  exposed 
to  tuberculosis.  In  all  this  work  the  Elizabeth  McCormick  Memorial 
Fund  has  had  the  co-operation  of  the  Board  of  Education,  the 
Chicago  Tuberculosis  Institute  and  the  Municipal  Tuberculosis 
Sanitarium.  The  Board  of  Education  has  supplied  teachers  and 
furnished  rooms  wherever  there  has  been  a  distinct  demand  for 
such  a  provision.  During  the  past  two  years  the  Municipal  Sani- 
tarium has  made  appropriations  aggregating  $12,000  to  pay  the 
cost  of  food  for  these  schools,  in  addition  to  furnishing  the  neces- 
sary nursing  service. 

At  the  present  time  four  Roof  Schools  and  sixteen  Open  Win- 
dow Rooms,  with  an  enrollment  of  500  pupils,  are  being  maintained. 

For  full  information  concerning  the  Chicago  Open  Air  School 
movement,  see  "Open  Air  Crusaders,"  January,  1913,  edition,  pub- 
lished by  the  Elizabeth  McCormick  Memorial  Fund,  315  Plymouth 
Court,  Chicago ;  or  write  Mr.  Sherman  C.  Kingsley,  Director,  Eliza- 
beth McCormick  Memorial  Fund,  for  more  recent  developments. 


Space  will  not  permit  a  statement  of  the  development  of  the 
Open  Air  Schools  in  other  cities  in  the  United  States  since  this 
movement  was  started  in  1908.  It  is,  however,  encouraging  to 
note  what  has  been  accomplished  and  the  comprehensive  plans 
which  are  being  made  to  further  this  great  movement  for  the  good 
of  the  future  citizens  of  America. 


65 


NOTES  ON  TUBERCULIN  FOR  NURSES 

VARIETIES  OF  TUBERCULIN— THEORIES  OF  TUBER- 
CULIN REACTION— TUBERCULIN  TESTS. 


By  THEODORE  B.  SACHS,  M.  D. 


VARIETIES  OF  TUBERCULIN  AND  METHODS 
OF  PREPARATION 

OLD  TUBERCULIN— T.    Announced  by  Koch  in  1890. 

Tubercle  Bacilli  of  human  origin. 

Grown  on  beef  broth  containing  5%   glycerine,  \%  peptone, 

sodium  chloride;  growths  6  to  8  weeks. 
Sterilized  by  steam  one-half  hour. 

Evaporated  (at  a  temp,  not  higher  than  70°  C.)  to  TV  its  volume. 
Filtered. 

1A  %  carbolic  acid  added.     Let  stand. 
Filtered  (porcelain  filter). 

Old  Tuberculin  contains : 

1.  40  to  50^  glycerine  (a  small  percentage  of  glycerine  is 

evaporated) 

2.  10%  of  peptones  or  albumoses 

3.  Toxic  secretions  of  the  tubercle  bacilli  into  the  culture  fluid, 

or  such  of  them  as  are  soluble  in  50%  glycerine 

4.  Substances  extracted  from  the  bacterial  bodies  by  the  alka- 

line broth  during  the  process  of  boiling  and  evaporation. 

Appearance  and  Characteristics : 

1.  A  clear  brown  fluid 

2.  Of  syrupy  consistency 

3.  Mixes  with  water  in  all  proportions  without  producing  any 

turbidity 

4.  Keeps  indefinitely,  but  not  advisable  to  use  brands  older  than 

one  year. 

56 


BOULLION  FILTRATE— B.  F.    Denys— 1907. 

Method  of  preparation  same  as  Old  Tuberculin,  with  the  ex- 
ception of  subjection  to  heat ; 

B.  F.  is  a  filtered,  unconcentrated  culture. 

Contains  less  peptone  and  less  glycerine  than  Old  Tuberculin. 

Contains  no  substances  extracted  from  tubercle  bacilli  by  heat 

Some  toxic  substances  may  be  more  active  (not  having  been  sub- 
jected to  heat). 

TUBERCULIN  RUCKSTAND  (Residue)— T.  R.    Announced  by  Koch  in 

1897. 

Ground,  dried  tubercle  bacilli 
Distilled  water  added 
Centrifugalization 

Supernatant  fluid  removed  (not  to  be  used) 
Sediment  dried  and  ground ;  distilled  water  added ;  centrif  ugal- 

ization 

Fluid  removed  and  set  aside. 
Sediment  dried  and  ground  again;  distilled  water  added;  cen- 

trifugalization 

Fluid  removed  and  set  aside 
Sediment  dried  and  ground,  etc.,  as  above. 
The  process  continued  until  water  takes  up  the  sediment,  then 

all  the  fluids  set  aside  (except  the  first  one)  mixed  together 
Glycerine  20%  added. 
The  mixture  is  T.  R. 

Koch  was  prompted  by  the  following  consideration  in  bringing  out 
T.  R.:    He  thought  that  the  Old  Tuberculin  conferred  only  a  toxic  im- 
munity, not  bacterial.    T.  R.  was  supposed  to  confer  bacterial  immunity. 
Each  1  cc.  of  T.  R.  contains  10  milligrams  of  dried  bacilli. 

BACILLEN  EMULSION— B.  E.    Announced  by  Koch  in  1901. 
Finely  powdered  tubercle  bacilli — 1A  gram. 
50  cc.  of  water  and  50  cc.  of  glycerine 
All  mixed  together — prolonged  shaking. 

B.  E.  is  supposed  to  contain  not  only  the  extract  of  the  body  of 
the  tubercle  bacilli,  as  in  T.  R.,  but  also  its  soluble  products 
(which  in  the  case  of  T.  R.  were  discarded  in  setting  aside  the 
supernatant  fluid). 

THEORIES  OF  TUBERCULIN  REACTION 

a  ROBERT  KOCH  ascribes  the  tuberculin  reaction  to  the  increased  ne- 
crotic  process  around  the  tubercle,  the  histological  changes  con- 
sisting of  hyperaemia,  exudation  and  softening. 

57 


b  EHRLICH  considers  the  formation  of  antibodies  an  essential  feature 
in  the  mechanism  of  reaction.  Formation  of  antibodies  takes  place 
in  the  middle  of  the  three  layers  encircling  the  tubercle,  the  layer 
damaged  by  toxins,  but  not  yet  rendered  incapable  of  reaction. 

c  WASSERMANN  maintains  that  the  antituberculin  found  in  the  tuber- 
culous process  draws  the  injected  tuberculin  out  of  the  circulation 
to  the  tuberculous  focus.  The  interaction  that  takes  place  be- 
tween antituberculin  and  tuberculin  results  in  formation  of  fer- 
ments which  digest  albumin,  resulting  in  the  softening  of  tissue. 
Absorption  of  softened  tissue  causes  fever. 

d  CARL  SPENGLER — Toxins  in  the  blood  of  the  tuberculous  are  kept  in 
check  by  antibodies.  Injected  tuberculin  unites  with  antibodies, 
thus  setting  the  toxins  free.  Result — autointoxication. 

e  WOLFF-EISNER — Bacteriolysin  is  present  in  the  organism  of  the  tuber- 
culous, as  result  of  previous  infection ;  bacteriolysin  sets  free  the 
potent  substances  of  the  injected  tuberculin;  this  acts  on  the 
body  and  the  tuberculous  focus,  producing  a  reaction,  t 

TUBERCULIN  TESTS 

I.  SUBCUTANEOUS  (hypodermic);  introduced  by  Robert  Koch  in  1890. 

II.  CUTANEOUS ;  introduced  by  Von  Pirquet  in  1907. 

III.  CONJUNCTIVAL  (ophthalmic);  introduced  about  the  same  time  by 

Wolff -Eisner  and  Calmette  in  1907. 

IV.  PERCUTANEOUS  (inunction  or  salve);  introduced  by  Moro  in  1908. 

V.  INTRACUTANEOUS  (needle  track  reaction);  introduced  as  a  test  by 

Mantoux  in  1909.    Described  previously  by  Escherich. 

I.    SUBCUTANEOUS  TUBERCULIN  TEST 
1.    APPARATUS  AND  SOLUTIONS  NECESSARY  : 

Glass  cylinder  graduated  to  cc. 
1  cc  pipette  graduated  to  TV  cc.  * 
10  cc  pipette  graduated  to  TV  cc.  * 
Hyperdermic  needle  suited  to  the  syringe 
Two  or  more  1A  oz.  bottles 
1A  %  carbolic  acid  solution 
Normal  salt  solution 
1  cc.  Old  Tuberculin. 

*    Not  absolutely  necessary ;  may  get  along  with  graduated  cylinder  and  syringe. 

\    For  a  diagrrammic  presentation  of  Wolff-Eisner's  theory,  see  "Tuberculin  Treatment"  by 
Riviere  and  Moreland,  page  6. 

58 


2.  PREPARATION  OF  APPARATUS  : 

Glass  apparatus,  syringe  and  needles  boiled  before  use. 
Some  keep  needles  and  syringe  in  95 %  alcohol. 

3.  MAKING  SOLUTIONS  : 

Tuberculin  No.  I  Tuberculin  No.  II 

Label  one  bottle  Another 

.1  cc.=l  mg.  T  .1  cc=.l  mg.  T 

'  Put  .1  cc.  T  in  bottle  No.  I 


1  Add  9.9  cc.  of  1A  %  carbolic  acid  solution 
f  Put  1  cc.  of  Tuberculin  solution  from 
No.  H<  No.  I  into  bottle  No.  II 

(  Add  9  cc.  of  1A  %  carbolic  solution 

In  making  dilutions  you  may  use  your  syringe  instead  of  pipette. 
Dilutions  can  be  kept  one  week  in  a  dark,  cool  place. 
Discard  turbid  solutions. 
4.    PREPARATION  OF  THE  PATIENT  FOR  THE  TEST  : 

Patient  to  keep  quiet  in  bed,  or  reclining  chair,  for  two  or  three 

days  before  injection. 
Take  temperature  every  two  or  three  hours  for  two  or  three 

days  (daytime). 

If  the  test  is  to  be  applied,  highest  temperature  should  not  be 
above  99.1  F,  by  mouth,  according  to  Koch;  not  above  100  F, 
according  to  others. 
Site  of  injection — back,  below  the  level  of  the  shoulder  blades, 

alternately  on  the  two  sides. 
Rub  skin  with  ether  or  alcohol. 

An  exact  record  of  physical  signs,  just  before  injection,  should 
be  made  by  the  physician. 

5  TIME  OF  INJECTION  : 

Between  8  and  10  A.  M.  (Bandelier  and  Roepke). 
Late  in  the  evening,  9  or  10  P.  M.,  or  later  (others). 

6  DOSE : 

According  to  Koch :    Begin  with  ^   mg.,  or  1  mg.,  according  to 
condition  of  patient ;  give  larger  dose  if  no  reaction.     Order 
of  increase :  1  mg.;  5  mg.;  10  mg.  (last  dose  repeated  if  necess- 
ary). 
Interval  between  injections :  two  or  three  days. 

Present  Usage :    First  dose  in  adults,  -|  mg.,  or  |  mg.,  or  smaller, 
according  to  physical  condition. 

First  dose  in  children :  ^  mg.,  or  -^  mg.,  or  even  smaller. 
Thus,  in  adults :  -|,  or  1,  3,  5,  8,  and  rarely  10; 
In  children,  y1^,  -|,   1,3. 

59 


Loewenstein  and  Kaufmann's  Scheme :  Repetition  of  small  dose, 
relying  on  exciting  hypersensibility  —  ^  mg. ;  in  3  days, 
121T  mg. ;  in  3  days,  ^  mg.;  in  3  days,  ^  mg. 

Some  use  T\y  mg.,  or  %,  or  1/4,  in  same  way. 

This  scheme  is  based  on  hypersensibility  created  by  repetition  of 
same  dose  in  tuberculous  subjects.  Scheme  not  used  at 
present. 

Some  advise  single  dose :  3  or  5  mg.,  (on  the  ground  that  grad- 
ual increase  of  doses  creates  tolerance). 

RULES  TO  FOLLOW  IN  INCREASING  DOSE  : 

a    If  no  reaction  with  one  dose,  give*  a  larger  one  next  time, 

according  to  b. 
b    If  temperature  rises  less  than  1  degree  F,  repeat  same  dose ; 

otherwise  increase. 
c    Avoid  large  doses  in  cases  of  weakness,  nervous  temperament, 

children,  etc.    In  a  majority  of  cases  smaller  doses  suffice. 

AFTER  INJECTION  : 

a  Rest  in  reclining  chair  two  or  more  days,  unless  severe  reaction 
requires  absolute  rest  in  bed. 

b    Take  temperature  every  2  or  3  hours  for  2  or  3  days. 
GENERAL  REACTION: 

a  Rise  of  Temperature.  Positive  reaction,  if  temperature  rises 
at  least  .5°  C.  (.9°  F.),  higher  than  previous  highest  temper- 
ature. C.  F. 

Degree  of  reaction  f  Slight  reaction  if  temp,  rises  to    38  or  100.4 

according  to  Band-  <  Moderate  "  "     to    39  or  102.2 

elier   and  Roepke  [  Severe      "       "     "        "  above  39  or  102.2 

Typical  reaction  temperature  curve:  Rapid  rise,  slower  fall, 
normal  temperature  after  24  hours. 

Rise  begins,  in  average  case,  6  to  8  hours  after  injection  (may 
begin  within  4  hours  or  be  delayed  for  30  hours). 

Acme  of  rise  in  9  to  12  hours 

Duration  of  reaction,  30  hours  or  longer. 

Rise,  acme  and  duration  of  reaction  vary. 

b    Symptoms : 

May  begin  with  rigor  or  chilliness,  followed  by  feeling  of  warmth. 

Following  symptoms  may  be  present : 

Malaise,  giddiness,  severe  headache,  pain  in  limbs,  pain  in 
affected  organ,  palpitation,  loss  of  appetite,  nausea,  vomiting, 
thirst,  sleeplessness,  lassitude,  etc. ;  in  short,  a  general  feeling 
of  "illness." 

With  fall  of  temperature — disappearance  of  symptoms. 

60 


10  REACTION  AT  POINT  OF  INJECTION  :    Area  of  redness,  sw  elling 

tenderness ;  important  as  indicative  of  sensitiveness,  pointing  to 
probable  general  reaction  with  repetition  or  increase  of  dose. 

11  FOCAL  REACTION :    Reaction  at  site  of  process,  due  to  congestion 

around  it. 

Focal  reaction  is  demonstrable  by : 
a    Change  in  physical  signs;    breath    sounds,   resonance, 

appearance  of  rales,  etc. 

b    Localizing  symptoms,  pointing  to  location  of  the  tuber- 
culous process. 
Lungs— increase  of  cough,  sputum,  appearance  of  bacilli, 

pain  in  chest,  etc. 
Kidney — pain  in  the  region  of  kidney,  changes  in  urine 

findings,  etc. 

Joint — swelling,  tenderness,  etc. 
Lupus — redness  and  exudation. 

Focal  reaction  is  an  important  feature  of  the  subcutaneous  tuber- 
culin test ;  it  permits  localization  of  the  disease  in  a  certain 
percentage  of  cases. 

Physical  examination,  sputum  examination,  urinalysis,  etc.,  are 
very  important  during  the  course  of  the  reaction. 

12  CONTRAINDICATIONS  : 

Subcutaneous  tuberculin  test  should  not  be  employed  in : 

1  Cases  with  temperature  above  100°  F,  by  mouth 
(99.1  °  F,  by  mouth,  according  to  Koch). 

2  Cases  in  which  the  clinical  history  and  physical  signs  make 
the  diagnosis  certain    (presence  of  tubercle  bacilli  in  the 
sputum  render,  of  course,  any  other  test  unnecessary). 

3  Cases  of  recent  haemoptysis. 

4  Grave  conditions,  as  severe  heart  disease,  nephritis,  marked 
arteriosclerosis,  etc. 

5  Convalescence  from  acute  infectious  diseases,  typhoid  fever, 
pneumonia,  etc. 

13  INTERPRETATION  OF  THE  POSITIVE  SUBCUTANEOUS  TUBERCULIN 
REACTION  : 

Occurrence  of  reaction,  following  the  subcutaneous  tuberculin 
test,  signifies  the  existence  of  infection;    it  does  not  signify 
that  the  individual  is  clinically  tuberculous.    To  quote  E.  R- 
Baldwin,  of  Saranac  Lake :     "The  tuberculin  test  is  of  very 
limited  value  in  determining  tuberculous  disease;    it  is  of 
extreme  value  in  detecting  tuberculous  infection." 
The  test  results  in  positive  reaction  in  cases  with  latent  as  well  as 
active  processes. 

61 


The  decision  as  to  the  patient  being  clinically  tuberculous  (ill  with 
tuberculosis)  must  rest  on  the  consideration  of  the  clinical  history  and 
the  results  of  the  physical  examination. 

It  is  maintained  by  some  that  the  subcutaneous  tuberculin  reaction 
is  more  rapid  in  onset  and  more  marked  in  degree  in  cases  of  recent 
infection.  On  the  other  hand,  the  test  is  negative  in  a  certain  propor- 
tion of  far  advanced  cases. 

Occurrence,  then,  of  a  subcutaneous  tuberculin  reaction  does  not 
indicate  necessarily  sanatorium  or  institutional  treatment ;  neither  does 
it  absolutely  indicate  the  necessity  of  tuberculin  treatment.  The  decis- 
ion rests  on  the  consideration  of  all  the  clinical  features  of  the  case. 

In  the  absence  of  any  symptoms  or  physical  signs  of  disease,  a 
reaction  should  call  for  regulation  of  every  day  life,  tending  to  increase 
the  state  of  general  resistance  (improvement  of  nutrition,  etc.)  frequent- 
ly without  discontinuance  of  work. 

The  occurrence  of  reaction,  in  the  presence  of  slight  symptoms  or 
physical  signs,  calls,  according  to  individual  condition,  either  for  home 
treatment  with  or  without  discontinuance  of  work,  or  sanatorium  treat- 
ment. 

14    INDICATIONS  FOR  THE  SUBCUTANEOUS  TUBERCULIN  TEST: 
The  following  considerations  should  guide  its  employment : 

1  A  thorough  study  of  the  history,  thorough  physical  examin- 
ation, examination  of  sputum  (if  any)  give  sufficient  data  for  a 
reliable  diagnosis  in  the  vast  majority  of  cases. 

2  Cases,  with    uncertain  symptoms  or  inconclusive  physical 
signs,  pointing  to  possible  existence  of  tuberculous  infection, 
may  be  treated  as  "suspicious"  cases  (without  resorting  to 
subcutaneous  tuberculin  test),  the  treatment  consisting  of  re- 
arrangement of  mode  of  life,  diet,  work,  etc.,  that  would  tend 
to  increase  of  general  resistance  of  the  patient.    This  can  and 
should  be  done  in  the  vast  majority  of  suspicious  cases. 

3  The  subcutaneous  tuberculin  test  is  indicated  in  cases  in  which, 
in  the  absence  of  conclusive  symptons  or  signs,  an  absolutely 
positive  diagnosis  is  desired ;  then  the  test  should  be  applied, 
with  the  consent  of  the  patient,  after  all  other  methods  of 
diagnosis    are   exhausted    (thourough    study    of  the    case, 
thourough  physical  examination,   repeated  examinations  of 
sputum,  etc). 

4  The  focal  reaction  (the  reaction  pointing  to  the  seat  of  the 
disease)  occurs  in  about  l/3 ,  or  less,  of  the  general  reactions 
following  the  subcutaneous  tuberculin  test ;  this  enhances  the 
value  of  the  test  in  some  cases  where  a  focal  reaction  would 
clear  the  diagnosis. 

62 


Above  all,  the  subcutaneous  tuberculin  test  should  be  used  rarely, 
and  then  only  after  all  other  methods  of  diagnosis  were  thouroughly 
applied. 

II.  CUTANEOUS  TUBERCULIN  TEST 

1  SYNONYMS  :  Von  Pirquet  Test  or  Skin  Test 

2  APPARATUS  AND  DILUTIONS  NECESSARY: 

Inoculation  needle  of  Von  Pirquet  Ether 

Koch's  Old  Tuberculin  (undiluted  or  Alcohol  lamp 

dilutions  according  to  method).  Medicine  dropper 

A  centimeter  tape  measure  (divided 
to  y-jy  cm.)  to  measure  reactions 

3  APPLICATION  OF  TEST  : 

Inner  surface  of  the  forearm ;  clean  the  site  with  ether ;  place  two 
drops  of  tuberculin  4  inches  apart ;  stretch  the  skin  and  scrape  off  the 
epidermis  (at  a  point  midway  between  the  two  drops  of  tuberculin)  by 
rotating  the  Von  Pirquet  needle  between  thumb  and  index  finger,  with 
slight  pressure  on  the  skin;  repeat  same  through  the  two  drops  of 
tuberculin  ;  let  the  tuberculin  soak  in  for  a  few  minutes.  No  dressing 
is  necessary.  The  middle  scarification  is  the  control  test.  One 
tuberculin  and  one  control  test  may  suffice.  A  separate  needle  should 
be  used  for  the  control  test. 

After  each  inoculation,  clean  the  needle  of  tuberculin  and  heat  the 
point  red  hot  in  the  alcohol  flame  before  applying  it  again. 

4  REACTION  : 

Gradual  elevation  and  reddening  of  skin  around  the  point  of  tuber- 
culin inoculation,  beginning  in  3  hours  or  later;  the  reaction  (papule) 
well  developed,  generally,  in  24  hours  and  most  distinct  in  48  hours 
after  inoculation. 

Size  of  papule  varies  from  a  diameter  of  10  millimeters  in  average 
case  to  20  mm.  occasionally,  and  30,  rarely  (Bandelier  and  Roepke) . 

At  the  end  of  48  hours  the  swelling  and  redness  subside  gradually, 
with  the  subsequent  bluish  discoloration  of  the  skin,  remaining  for 
various  periods  of  time,  and  slight  peeling  of  the  epidermis.  Individual 
reactions  vary  in  degree  of  redness,  elevation,  size,  contour  of  the 
border,  etc.  All  these  points  should  be  observed  and  recorded. 

Time  of  inspection — 24  and  48  hours  after  inoculation. 

Single  inspection — best  time  in  48  hours. 

5  CAUSE  OF  REACTION  : 

Interaction  between  inoculated  tuberculin  and  the  antibodies 
(bacteriolysins,  according  to  Wolff -Eisner)  present  in  the  skin  of  a 
tuberculous  individual ;  interaction  results  in  hyperaemia  and  exuda- 
tion (papule). 

63 


6    INTERPRETATION  OF  REACTION  : 

Occurrence  of  positive  reaction  signifies  presence  of  a  tuberculous 
focus  somewhere  in  the  body.  No  indication  as  to  activity  or  location 
of  the  focus. 

A  negative  reaction  in  adults  (especially  if  repeated)  signifies 
non-existence  of  tuberculosis  (unless  great  deterioration  of  health,  far 
advanced  process,  or  tolerance  to  tuberculin  established  by  tuberculin 
treatment). 

A  positive  reaction  in  children  under  two  years  of  age  signifies, 
generally,  active  tuberculous  process;  with  the  advance  of  age  the 
determination  of  active  tuberculous  processes  by  means  of  cutaneous 
tuberculin  test  becomes  impossible. 

III.  CONJUNCTIVAL  TUBERCULIN  TEST 

1  SYNONYMS :  Eye  Test ;  Ophthalmic  Test ;  Wolff -Eisner's  Test ;  Cal- 

mette's  Test. 

2  APPARATUS  AND  DILUTIONS  NECESSARY  : 

1  cc.  pipette  graduated  to  T\  cc. 

10  cc.  pipette  graduated  to  ^  cc. 

10  cc.  glass  cylinder 

Medicine  dropper 

Koch's  Old  Tuberculin 

1A  %  and  1  %  dilution  of  Old  Tuberculin  in 

.85  $>  sterile  normal  salt  solution. 
To  make  \%  dilution,  add  .Ice.  Old  Tuberculin  to9.9cc.  of  diluent. 

3  APPLICATION  OF  TEST  : 

Patient  sitting,  with  head  thrown  back 

Lower  eyelid  drawn  slightly  down  and  toward  the  nose — to  form 

a  small  pouch  of  the  lid ; 
One  drop  of  1  %  or  1A  %  instilled  in  that  pouch  and  the  lower 

lid  moved  up  gently  over  the  eye  until  the  lids  meet ; 
Eye  kept  closed  for  one  minute  or  so. 

4  REACTION  .- 

Onset  in  12  to  24  hours  (may  begin  earlier)  ;  acme  in  24  to  36 
hours ;  duration  of  reaction — 3  to  4  days  or  even  longer  (in  severe 
cases).  Some  reactions  are  of  short  duration.  3  grades  of  reaction, 
according  to  Citron : 

1  Reddening  of  caruncle  and  palpebral  (lid)  conjunctiva. 

2  More  intense  reddening,  with  involvement  of  ocular  (eyeball) 
conjunctiva,  and  increased  secretion. 

3  Very  intense  reddening  of  the  whole  conjunctiva,  with  much 
fibrinous  and  purulent  secretion,  etc. 

64 


5  TIME  OF  INSPECTION  : 

12  and  24  hours  after  instillation;  then  once  a  day. 

6  CAUSE  OF  REACTION  : 

Hyperaemia  and  exudation  resulting  from  interaction  between 
instilled  tuberculin  and  antibodies  in  conjunctiva  (bacteriolysin,  accord- 
ing to  Wolff -Eisner). 

7  INTERPRETATION  OF  REACTION  : 

Wolff -Eisner  maintains  that  positive  conjunctival  tuberculin  react- 
ion means  active  tuberculosis,  a  conclusion  accepted  by  but  a  few. 

8  FIELD  OF  APPLICATION  OF  CONJUNCTIVAL  TUBERCULIN  TEST  : 

Should  not  be  used ;  connected  with  danger  to  the  eye. 
Conjunctival  test  used  very  rarely  at  present. 

IV.    PERCUTANEOUS  TUBERCULIN  TEST 

1  SYNONYMS  :  Salve  Test ;  Moro  Test. 

2  SALVE :   Equal  parts  of  Old  Tuberculin  and  anhydrous  lanolin 

3  APPLICATION  OF  TEST  : 

Site :  abdominal  wall  below  ensiform  process,  or  breast  below 

nipple,  or  inner  surface  of  forearm. 
Application :  rub  in  with  the  finger  (using  moderate  pressure) 

a  small  particle  of  salve  about  the  size  of  a  pea. 
Rub  it  in  into  an  area  about  5  cm. ;  rub  1  minute. 

4  REACTION  : 

In  24  to  48  hours — either  numerous  small  reddened  spots  which 
disappear  in  a  few  days,  or  numerous  small  nodules,  or  coalescing 
nodules  on  a  red  base,  etc. 

5  INTERPRETATION  OF  REACTION  : 

Positive  reaction  is  assumed  to  indicate  existing  tuberculous  infect- 
ion somewhere  in  the  body ;  does  not  indicate  that  the  process  is  active. 

6  FIELD  OF  APPLICATION  OF  PERCUTANEOUS  TUBERCULIN  TEST  : 

The  percutaneous  tuberculin  test  fails  in  a  large  proportion  of 
tuberculosis  cases. 

The  test  is  used  rarely  at  present. 

LIGNIERES  TEST 

A  modification  of  the  Moro  Test 

Instead  of  salve,  a  few  drops  of  Old  Tuberculin  rubbed  in. 

Used  rarely  at  present. 

65 


V.    INTRACUTANEOUS  TUBERCULIN  TEST 

1  SYNONYMS— Mantoux  Test 

2  APPLICATION  OF  TEST  : 

Injection  into  skin  (needle  parallel  to  skin)  of  y^  mg.  of  Old 
Tuberculin  (according  to  Mantoux). 

3  REACTION  : 

Onset  in  a  few  hours,  well  developed  in  24  hours,  acme  in  48 
hours.  Reaction  consists  of  a  central  nodule  surrounded  by  a 
halo  of  redness. 

This  is  the  intracutaneous  test  as  originally  suggested  by 
Mantoux. 

CONCLUSIONS 

Comparing  the  various  tuberculin  tests  we  find  that : 

1  The  Subcutaneous  Tuberculin  Test  has  the  advantage  of  focal  re- 
action, disclosing  in  a  certain  percentage  of  cases  the  seat  of  the  disease. 

The  subcutaneous  test  should,  however,  never  be  employed  unless 
as  a  last  resort,  and  then  only  after  all  other  methods  of  diagnosis  are 
exhausted  and  an  absolute  diagnosis  is  very  essential. 

In  the  vast  majority  of  suspected  cases  of  tuberculosis,  thorough 
study  of  the  history  of  the  case,  combined  with  thorough  physical 
examination,  furnishes  all  the  necessary  data  for  diagnosis  and  an  effi- 
cient plan  of  treatment. 

2  The  Cutaneous  Tuberculin  Test  is  a  very  efficient  diagnostic 
measure  in  children  under  two  years  of  age  in  whom  a  positive  cutaneous 
tuberculin  reaction  indicates  active  disease. 

Positive  cutaneous  tuberculin  reaction  in  adults  indicates  existence 
of  a  tuberculous  process,  somewhere  in  the  body ;  it  does  not  indicate 
that  the  process  is  active. 

Negative  cutaneous  tuberculin  reaction  is  one  of  the  corroborative 
evidences  of  absence  of  tuberculosis,  unless  reaction  is  prevented  by 
very  advanced  disease  or  tolerance  to  tuberculin  established  by  tuber- 
culin treatment. 

3  Thorough  study  of  the  history  and  thorough  physical  examina- 
tion of  each  individual  case  are  more  important  and  should  precede  the 
application  of  any  test. 


